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Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care
Contraception 90 (2014) 429 – 434
Original research article
Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care☆,☆☆,★ Maryam Guiahi⁎, Jeanelle Sheeder, Stephanie Teal University of Colorado Anschutz Medical Center, Department of Obstetrics and Gynecology, Section of Family Planning Received 2 April 2014; revised 3 June 2014; accepted 15 June 2014
Abstract Objective: To understand if women anticipate a difference in reproductive healthcare when attending a Catholic institution. Study design: A convenience sample of reproductive-aged women in the Denver metro area completed an online survey. Women were randomized to hypothetical women’s health clinics at either a secular or Catholic hospital and asked about expectations for family planning care. Questions covered contraception and management of abnormal or unintended pregnancy. We subsequently assessed provider/site preferences for care. Results: We analyzed 236 surveys. The majority of participants expected their gynecologist to provide all family planning services presented. The only difference based on institution was that participants randomized to the Catholic hospital were more likely to expect natural family planning advice. At least half of respondents reported they would seek care from their gynecologist for the services surveyed with the exceptions of emergency contraception and elective abortion. Conclusions: Overall, this cohort of women did not anticipate differences in reproductive healthcare based on institution. If women who enroll at Catholic hospitals do not receive information related to potential healthcare restrictions, their ability to act as informed healthcare consumers may be constrained. Implications: Women did not anticipate differences in reproductive healthcare based on institution type (Catholic vs. secular) and, thus, their ability to act as informed healthcare consumers may be constrained. © 2014 Elsevier Inc. All rights reserved. Keywords: Family planning; Catholic hospital; Patient expectations; Women's healthcare
1. Introduction The Catholic Church exerts major influence over the US healthcare system by overseeing the largest group of not-forprofit healthcare sponsors, systems, and facilities. In 2011, 10% of all acute-care hospitals were Catholic-sponsored or affiliated and about one in nine beds were at such a facility [1]. The federal government designated 30 of these Catholic ☆
Funding was received from the Academic Enrichment Fund of the University of Colorado Department of Obstetrics and Gynecology. ☆☆ To be presented as an oral abstract at the North American Forum on Family Planning on October 12, 2014 in Miami, Florida. ★ Requests for reprints can be sent to the corresponding author. ⁎ Corresponding author. University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, 12631 E. 17th Ave Room 4203, Mailstop B192-2, Aurora, Colorado 80045. E-mail address: [email protected] (M. Guiahi). http://dx.doi.org/10.1016/j.contraception.2014.06.035 0010-7824/© 2014 Elsevier Inc. All rights reserved.
hospitals as the “sole community providers [1].” The number of patients cared for at Catholic hospitals has also increased over the past two decades as the number of mergers increased; in 2011, 10 of the top 25 health systems in the United States were Catholic [1]. When women are cared for at Catholic owned hospitals they face several restrictions to reproductive health care including access to birth control methods, emergency contraception, and miscarriage management [1–6]. Many obstetrician-gynecologists (OB/ GYNs) who practice at religiously affiliated institutions have reported conflicts with religious policies for patient care, deemed some of these restrictions to be unacceptable when caring for women, and/or reported that such restrictions have interfered with clinical management [6–8]. Most patients seek out primary care providers (PCPs) or hospitals based on recommendations from friends and relatives, recommendations from doctors or other health
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care providers, information supplied by their health plans and/or geographical proximity; there is no data that patients primarily attend faith-based institutions for religious considerations [9–11]. Data on patients’ expectations of reproductive health care at Catholic institutions is scant, but there is some evidence that patient’s may be very surprised to learn of limitations [12,13]. A public opinion research poll of 1000 women conducted in 2000 found that the majority expected a full range of reproductive health services regardless of religious affiliation and 45% believed they would be able to obtain medical service that go against Catholic religious teachings [14]. Given that receiving care at a Catholic institution does not appear to be primarily motivated by patients’ religious beliefs, we wanted to test the hypothesis that women do not anticipate a difference in care when attending a Catholic medical institution.
2. Materials and methods We approached a convenience sample of women in the Denver area to assess expectations and preferences for family planning care. Reproductive aged women (18-45 years) who were able to read English or Spanish were eligible for participation. Women answering our online or printed advertisements were directed to a website where they completed a brief survey to determine eligibility. Eligible women were then randomized to read a vignette describing one of two clinical scenarios (Fig. 1). The scenarios were identical except for the name of the institution; one was a hypothetical Catholic hospital (St. Ignatius Hospital of Denver) and the other a hypothetical secular one (Metropolitan Hospital of Denver). Following display of each vignette, the participant completed a survey which asked if
the participant would expect to receive care for a comprehensive list of family planning services at the institution to which they were assigned, such as, “If I wanted, to go on “the pill” for birth control, I would expect that my OB/GYN at St. Ignatius/Metropolitan Hospital would prescribe it.” The participant was given the option of answering “yes,” “no,” or “I don’t know.” Secondarily, we assessed participants’ preferences for care using the same list of family planning services, specifying that the participant should indicate her personal preference and that she should no longer consider herself a patient of the theoretical vignette. For each service we asked where she would seek care using the answer selections of “my OB/GYN,” “my primary care provider (example: nurse practitioner, family doctor),” “a clinic like Planned Parenthood,” “Other- please specify,” or “I would never request this service.” Next, we assessed demographic, reproductive and gynecologic characteristics. Finally, we included an optional response box for open-ended comments after completion of the survey questions. We initially piloted the survey in-person to ten participants to assess readability and absence of ambiguity; based on this feedback, the survey was revised. We advertised the survey online with Craigslist and Facebook and placed fliers in multiple locations throughout the Denver Metropolitan area. Facebook advertisements were in English only, Craigslist advertisements and fliers were in English and Spanish. Participants who completed the survey received a $5 gift card to a local supermarket or coffee shop. Study data was collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at University of Colorado. REDCap is a secure, web-based application designed to support data capture for research studies. This publication was supported by NIH/NCRR
Fig. 1. Introductory scenarios given to participants based on randomization.
M. Guiahi et al. / Contraception 90 (2014) 429–434
Colorado CTSI Grant Number UL1 RR025780. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views. We hypothesized that women surveyed about routine gynecologic family planning care will have similar expectations whether the care is provided at a Catholic versus a secular institution. Our hypothesis assumed equivalent expectations for provision of non-abortion family planning between patients at Catholic and standard health care systems. We calculated the sample size using Blackwelder’s formula for equivalence: (Z 0.95 + Z 0.80) 2 [Ps(1-Ps) + Pn(1Pn)]/(Ps-Pn-D) 2, where Ps is the proportion of positive results in the standard group, Pn is the proportion in the novel group, and D represents the greatest difference that is considered equivalent. We estimated that 90% of patients given each clinical setting would expect their gynecologist to provide non-abortion contraceptive care, with D=0.1, α= 0.05, and power of 80%. The required sample size was 111 in each group, or 222 total participants. We aimed to recruit 240 to account for incomplete surveys. Summary statistics were used to describe the population and the outcomes. Means were compared using the Student’s t-test and proportions compared using the X 2 test, or Fisher’s exact test for small cell sizes. IBM SPSS Statistics (version 21.0.0) was used for all analyses. The study was approved by the Colorado Multiple Institutional Review Board (COMIRB).
3. Results After exclusion of incomplete surveys, a total of 236 surveys were completed between February 11 2013-May 16 2013 and included in our analysis; 115 were randomized to Metropolitan hospital, 121 to St. Ignatius hospital. Table 1 demonstrates participant characteristics. The majority of participants were young, white, non-Hispanic/Latino, single women who have never been pregnant. The most commonly identified religion was either agnostic/atheist/no religion and the majority had completed an undergraduate or graduate degree. Most of our participants reported having commercial insurance and receiving routine gynecologic care. Overall, characteristics were similar between groups. Seventy-four percent of our participants reported where they usually receive their gynecologic care: 30% went to an OB/GYN clinic, 16% to a non-GYN primary care clinic, 8% to Planned Parenthood, 6% to student health clinic, and 40% reported a clinic/hospital but did not specify if the type of care they received there was from an OB/GYN or other provider. Table 2 demonstrates participant responses to our questions about expectations for care. Regardless of institution type, the majority of participants expected that their gynecologist would provide the range of family planning care surveyed. Over 90% of participants expected to receive short and long-acting reversible contraceptive methods at either facility. Lower proportions of participants expected care for abortion care services at either institution.
431
Table 1 Participant demographics Characteristic
Metropolitan St. Ignatius P-value Hospital of Denver Hospital of Denver (n=115) (n, %) (n=121) (n, %)
Age (Mean, [SD]) 27.2 (6.3) Race White 90 (78.3) American 1 (0.9) Indian/Alaskan Asian 3 (2.6) Black/African 4 (3.5) American N. Hawaiian/ 2 (1.7) Pacific Islander Other 15 (13) Ethnicity Hispanic/Latino 26 (22.6) Not 89 (77.4) Hispanic/Latino Marital status Single 72 (62.6) Married 36 (31.3) Separated/ 7 (6.1) divorced/other Ever pregnant 51 (44.3) Has given birth 35 (30.4) at least once Religion Catholic 28 (24.3) Christian/ 28 (24.3) Protestant Other religion 13 (11.3) Agnostic/Atheist/ 46 (40.0) No Religion Insurance Commercial 81 (70.4) Public 7 (6.1) (i.e.: Medicaid) Student 12 (10.4) No insurance 15 (13.0) Educational experience Less than 2 (1.8) high school High school 12 (10.8) degree/GED/ Vocational school Some college 33 (28.9) Undergraduate 35 (30.7) degree Graduate degree 32 (28.1) Receives routine 86 (76.1) gynecologic care
28.8 (6.8)
0.05 0.08
105 (86.8) 0 (0) 4 (3.3) 7 (5.8) 0 (0) 5 (4.1) 0.09 17 (14.0) 104 (86.0) 0.60 68 (56.2) 45 (37.2) 8 (6.6) 42 (34.7) 32 (26.4)
0.14 0.56 0.12
21 (17.6) 46 (38.7) 11 (9.2) 41 (34.5) 0.89 89 (73.6) 5 (4.1) 13 (10.7) 14 (11.6) 0.40 0 (0) 12 (9.9)
35 (28.9) 47 (38.8) 27 (22.3) 98 (81.0)
0.43
The only difference between expectations for family planning care by institution type was for natural family planning advice; participants given the hypothetical example of attending St. Ignatius were more likely to expect natural family planning advice (OR=7.4; 95% confidence interval 1.6, 33.7). (See Table 2.)
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Table 2 Participant responses for expectations for care Family planning method
Metropolitan Hospital of Denver (n=115) (n, %)
Natural family planning advice Yes No I don’t know Provide a diaphragm Yes No I don’t know Prescribe birth control pill Yes No I don’t know Provide Depo-provera® (the shot) Yes No I don’t know Get an intrauterine device (IUD) Yes No I don’t know Prescribe emergency contraception (Plan B® or morning after pill) Yes No I don’t know Perform sterilization (to get my tubes tied) Yes No I don’t know Provide treatment of a miscarriage (D&C) Yes No I don’t know End a pregnancy with a lethal abnormality (baby will not live more than one year if born) Yes No I don’t know End a pregnancy with a genetic abnormality (i.e. Downs syndrome) Yes No I don’t know End a normal pregnancy (for personal reasons) Yes No I don’t know
After ascertaining the care women expected at clinics at each institution, we asked participants where they would go for reproductive health care to assess the likelihood that women’s expectations of care will be met (Table 3). Over 80% of respondents chose their OB/GYN or PCP for all short or long-acting reversible contraceptive methods. “A clinic like Planned Parenthood” was chosen by 9-12%. If the participant needed a termination for a lethal abnormality, 66% expected to go to her OB/GYN or PCP for care. Fewer women, but still a majority, would go to their primary provider for emergency contraception (56%) and elective termination of pregnancy (50%).
St. Ignatius Hospital of Denver (n=121) (n, %)
P-value
b0.01 98 (86.0) 13 (11.4) 3 (2.6)
112 (93.3) 2 (1.7) 6 (5.0)
105 (91.3) 6 (5.2) 4 (3.5)
112 (93.3) 4 (3.3) 4 (3.3)
110 (95.7) 2 (1.7) 3 (2.6)
111 (92.5) 5 (4.2) 4 (3.3)
108 (94.7) 5 (4.4) 1 (0.9)
110 (90.9) 6 (5.0) 5 (4.1)
107 (93.9) 6 (5.3) 1 (0.9)
108 (90.0) 7 (5.8) 5 (4.2)
92 (81.4) 14 (12.4) 7 (6.2)
93 (78.2) 21 (17.6) 5 (4.2)
94 (82.5) 8 (7.0) 12 (10.5)
96 (80.0) 14 (11.7) 10 (8.3)
99 (86.8) 5 (4.4) 10 (8.8)
108 (91.5) 3 (2.5) 7 (5.9)
79 (68.7) 16 (13.9) 20 (17.4)
79 (65.3) 23 (19.0) 19 (15.7)
72 (63.7) 24 (21.2) 17 (15.0)
65 (54.2) 34 (28.3) 21 (17.5)
67 (58.3) 32 (27.8) 16 (13.9)
58 (47.9) 44 (36.4) 19 (15.7)
0.77
0.52
0.28
0.27
0.45
0.43
0.51
0.57
0.32
0.27
4. Discussion In this study, we randomly assigned a convenience sample of reproductive-aged women living in a major metropolitan area to answer questions about expected care at one of two hypothetical women’s health clinics: one at a Catholic hospital, and one at a secular institution. Our convenience sample is similar to Denver’s demographics. Demographic statistics from 2008-2012 demonstrate that the majorities are white (74%), not Hispanic/Latino (68%), and almost half have completed a bachelor’s degree or higher (48%) [15]. Forty-seven percent of Denver county habitants
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Table 3 Participants responses to where they would seek care based on family planning methods Family planning method
OB/ GYN
PCP
Family I would Other Planning Clinic never request
Advice about natural family planning methods (such as withdrawal or the rhythm method) A diaphragm for birth control To go on the pill for birth control Depo-provera (the shot) for birth control An intrauterine device (IUD) for birth control Emergency contraception (Plan B or the morning after pill) Sterilization (to get my tubes tied) Desired a D&C for a miscarriage End a pregnancy complicated by a lethal abnormality (baby will not live more than one year if born) End a pregnancy with a genetic abnormality (i.e. Downs syndrome) End a pregnancy (i.e. for personal reasons)
53.2% 62.0% 60.7% 60.7% 73.9% 40.7% 78.2% 80.9% 61.8% 51.9% 44.9%
19.6% 18.8% 25.2% 22.2% 12.8% 15.2% 12.4% 9.6% 4.3% 5.2% 4.7%
10.2% 12.0% 11.1% 9.4% 9.0% 29.0% 4.3% 7.4% 16.3% 17.6% 28.2%
14.9% 7.3% 3.0% 7.7% 4.3% 6.5% 4.3% 2.2% 16.3% 24.0% 21.8%
2.1% 0% 0% 0% 0% 8.7% 0.9% 0% 1.3% 1.3% 0.4%
OB/GYN: obstetrician/gynecologist, PCP: primary care physician.
do not affiliate with a religious congregation, similar to our finding that the majority of participants reported that they are agnostic/atheist/no religion [16]. Importantly, the majority of our participants were young, single women who have never been pregnant and therefore represent a population likely to access family planning services. We assessed expectations for family planning care and their setting preferences for reproductive health care. We hypothesized that women would have similar expectations despite defined policies limiting reproductive health care practices at Catholic health care facilities. We found that most women in our survey expect that their OB/GYN will provide the full range of family planning services, regardless of institution type. The majority also choose to seek care from their OB/GYN for most of the services surveyed. Unlike other services, almost one-third of participants selected Planned Parenthood as a place of care when the patient needed emergency contraception or an elective termination. This is consistent with Weitz and Cockrill’s report on patients presenting to abortion clinics across the US heartland; they found that the majority of these women sought abortion care at a free-standing clinic rather than from their general provider [17]. Our study findings have important public health implications. Many Catholic institutions limit reproductive healthcare options based on religious doctrines and these limitations have health repercussions [1–8]. At one Jesuit hospital, limitations on immediate postpartum contraception in the form of depot medroxyprogesterone acetate resulted in higher repeat pregnancy rates for adolescents and young adult women [2]. Two qualitative studies describe the experiences of physicians working in Catholic hospitals; many of the doctors were conflicted with the Catholic hospital polices that interfered with management of obstetrical emergencies such as incomplete abortion, molar pregnancies, and previable premature rupture of membranes as they were perceived by hospital authorities to require treatment in the form of abortion care [6,8]. Further the ethical and religious directives of Catholic hospitals directly prohibit abortion care and instruct Catholic health care
institutions “to be concerned about the danger of scandal in any association with abortion providers” [18]. Thus for women presenting to their PCP with the expectation of abortion care or a referral to an abortion provider, these directives will directly inhibit care and likely lead to greater delays and additional stigmatization. It appears that our cohort of women did not anticipate a difference in reproductive healthcare at a Catholic institution other than for natural family planning advice. Thus, women who seek care at religiously affiliated hospitals may not recognize that their healthcare options are influenced by religious doctrines. As Wall discusses, in the late nineteenth and early twentieth centuries, Catholic hospitals’ religious affiliations were more obvious as nuns attended to patients and the halls were filled with obvious religious paraphernalia; today’s hospitals are less reflective of religious ties and more reflective of general medical care [19]. If women who enroll at Catholic hospitals do not receive information related to potential healthcare restrictions, their ability to act as informed healthcare consumers may be constrained. This study has several limitations. Although the demographics of this convenience sample were comparable to Denver overall, and were similar between groups, it is possible that patients attending Catholic hospitals differ. Traditionally, Catholic hospitals were recognized for the increased care they provide to underserved and uninsured patients, who likely represent a cohort of women that may differ in terms of educational, financial, and religious demographics than our sample. Recently, however, reports demonstrate that Catholic hospitals and secular hospitals bill Medicare and Medicaid similarly, and most patients choose a hospital for reasons other than religiosity [1,9–11]. Further, use of a convenience sample has the inherent limitation of selection bias. This was a survey about a hypothetical situation that implied one secular hospital and one Catholic hospital. We chose to not explicitly label St. Ignatius a Catholic hospital in order to avoid emphasizing the primary objective of the study. When a patient actually enters a Catholic hospital she may have different expectations. Participants may have considered St. Ignatius to be a Christian rather than Catholic
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hospital, or even a secular hospital with a traditional religious name. Four Denver hospitals have religiously affiliated names: 3 are Catholic and one is secular. Thus, some participants may have attended this last hospital and not experienced restrictions to care; this may have impacted our results. As a greater proportion of our patients randomized to St. Ignatius expected counseling regarding natural family planning, however, it suggests that they considered it to be a Catholic hospital. Future research should query patients seeking well-women care at Catholic hospitals about expectations of family planning services; we received human subjects’ approval to conduct surveys at a secular and a Catholic hospital, but our attempts to receive institutional approval were ultimately unsuccessful. Our data provide a valuable contribution to local and national discussions of the rise of hospital mergers and employer-based insurance limitations on reimbursement for family planning services. Women expect and prefer contraceptive care from their own PCP or OB-GYN. Reliance on dedicated family planning clinics such as Planned Parenthood for primary preventative care such as contraception is common and reflects how these clinics have filled a gap in women’s healthcare. The Institute of Medicine outlines six performance expectations for the 21st century healthcare system: care must be safe, timely, effective, efficient, patient centered, and equitable. [20]. Deferring women’s healthcare needs at Catholic hospitals and associated institutions falls far short of these aims. References [1] Uttley L, Reynertson S, Kenny L, Melling L. Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat of Reproductive Health Care. New York, NY: The MergerWatch Project and the American Civil Liberties Union; 2013. [2] Guiahi M, McNulty M, Garbe G, Edwards S, Kenton K. Changing depot medroxyprogesterone acetate access at a faith-based institution. Contraception Sep 2011;84(3):280–4. [3] Polis C, Schaffer K, Harrison T. Accessibility of emergency contraception in California's Catholic hospitals. Women's health issues: official publication of the Jacobs Institute of Women's Health, 15. 4; 2005, pp. 174–8. [4] Harrison T. Availability of emergency contraception: a survey of hospital emergency department staff. Ann Emerg Med 2005;46 (2):105–10.
[5] Temin E, Coles T, Feldman JA, Mehta SD. Availability of emergency contraception in Massachusetts emergency departments. Acad Emerg Med 2005;12(10):987–93. [6] Freedman LR, Landy U, Steinauer J. When there's a heartbeat: miscarriage management in Catholic-owned hospitals. Am J Public Health Oct 2008;98(10):1774–8. [7] Stulberg DB, Dude AM Dahlquist I, Curlin FA. Obstetriciangynecologists, religious institutions, and conflicts regarding patientcare policies. Am J Obstet Gynecol 2012;207(1):73.e71–5. [8] Freedman LF, Stulberg DB. Conflicts in care for obstetric complications in Catholic hospitals. AJOB Primary Research, 4. 4; 2013, pp. 1–10. [9] Tu HLJ. Word of Mouth and Physician Referrals Still Drive Health Care Provider Choice. HSC Research Brief No. 9; 2008 [ http://www. hschange.com/CONTENT/1028/. Accessed 3/7/2014]. [10] Salisbury CJ. How do people choose their doctor? BMJ 1989;299 (6699):608–10. [11] Wun YT, Lam TP, Lam KF, Goldberg D, Li DK, Yip KC. How do patients choose their doctors for primary care in a free market? J Eval Clin Pract Dec 2010;16(6):1215–20. [12] Eckholm E. Bishops Sued Over Anti-Abortion Policies at Catholic Hospitals. The New York Times; 2013. [13] Raghavan R. A piece of my mind. A question of faith. JAMA 2007;297 (13):1412. [14] Russonello Belden, Stewart. Religion, Reproductive Health and Access to Services: A National Survey of Women. Washington, D.C. http://www.catholicsforchoice.org/topics/healthcare/documents/ 2000religionreproductivehealthandaccesstoservices.pdf2000. [15] United States Census Bureau, American Fact Finder. ACS Demographic and Housing Estimates 2008-2012, American Community Survey 5-Year Estimates. Available from: http://factfinder2.census. gov/faces/tableservices/jsf/pages/productview.xhtml? pid=ACS_12_5YR_DP05. [16] City-Data.com. Denver County, Colorado (CO) Religion Statistics Profile – Denver. Available from: http://www.city-data.com/county/ religion/Denver-County-CO.html. [17] Weitz TA, Cockrill K. Abortion clinic patients' opinions about obtaining abortions from general women's health care providers. Patient Educ Couns 2010;81(3):409–14. [18] United States Conference of Catholic Bishops. Ethical and religious directives for Catholic Health Care Services. Available from: http:// www.usccb.org/issues-and-action/human-life-and-dignity/health-care/ upload/Ethical-Religious-Directives-Catholic-Health-Care-Servicesfifth-edition-2009.pdf2009. [19] Wall BM. American Catholic Hospitals: A Century of Changing Markets and Missions. New Brunswick, New Jersey, and London: Rutgers University Press; 2011. [20] Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century; 2001.
Original research article
Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care☆,☆☆,★ Maryam Guiahi⁎, Jeanelle Sheeder, Stephanie Teal University of Colorado Anschutz Medical Center, Department of Obstetrics and Gynecology, Section of Family Planning Received 2 April 2014; revised 3 June 2014; accepted 15 June 2014
Abstract Objective: To understand if women anticipate a difference in reproductive healthcare when attending a Catholic institution. Study design: A convenience sample of reproductive-aged women in the Denver metro area completed an online survey. Women were randomized to hypothetical women’s health clinics at either a secular or Catholic hospital and asked about expectations for family planning care. Questions covered contraception and management of abnormal or unintended pregnancy. We subsequently assessed provider/site preferences for care. Results: We analyzed 236 surveys. The majority of participants expected their gynecologist to provide all family planning services presented. The only difference based on institution was that participants randomized to the Catholic hospital were more likely to expect natural family planning advice. At least half of respondents reported they would seek care from their gynecologist for the services surveyed with the exceptions of emergency contraception and elective abortion. Conclusions: Overall, this cohort of women did not anticipate differences in reproductive healthcare based on institution. If women who enroll at Catholic hospitals do not receive information related to potential healthcare restrictions, their ability to act as informed healthcare consumers may be constrained. Implications: Women did not anticipate differences in reproductive healthcare based on institution type (Catholic vs. secular) and, thus, their ability to act as informed healthcare consumers may be constrained. © 2014 Elsevier Inc. All rights reserved. Keywords: Family planning; Catholic hospital; Patient expectations; Women's healthcare
1. Introduction The Catholic Church exerts major influence over the US healthcare system by overseeing the largest group of not-forprofit healthcare sponsors, systems, and facilities. In 2011, 10% of all acute-care hospitals were Catholic-sponsored or affiliated and about one in nine beds were at such a facility [1]. The federal government designated 30 of these Catholic ☆
Funding was received from the Academic Enrichment Fund of the University of Colorado Department of Obstetrics and Gynecology. ☆☆ To be presented as an oral abstract at the North American Forum on Family Planning on October 12, 2014 in Miami, Florida. ★ Requests for reprints can be sent to the corresponding author. ⁎ Corresponding author. University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, 12631 E. 17th Ave Room 4203, Mailstop B192-2, Aurora, Colorado 80045. E-mail address: [email protected] (M. Guiahi). http://dx.doi.org/10.1016/j.contraception.2014.06.035 0010-7824/© 2014 Elsevier Inc. All rights reserved.
hospitals as the “sole community providers [1].” The number of patients cared for at Catholic hospitals has also increased over the past two decades as the number of mergers increased; in 2011, 10 of the top 25 health systems in the United States were Catholic [1]. When women are cared for at Catholic owned hospitals they face several restrictions to reproductive health care including access to birth control methods, emergency contraception, and miscarriage management [1–6]. Many obstetrician-gynecologists (OB/ GYNs) who practice at religiously affiliated institutions have reported conflicts with religious policies for patient care, deemed some of these restrictions to be unacceptable when caring for women, and/or reported that such restrictions have interfered with clinical management [6–8]. Most patients seek out primary care providers (PCPs) or hospitals based on recommendations from friends and relatives, recommendations from doctors or other health
430
M. Guiahi et al. / Contraception 90 (2014) 429–434
care providers, information supplied by their health plans and/or geographical proximity; there is no data that patients primarily attend faith-based institutions for religious considerations [9–11]. Data on patients’ expectations of reproductive health care at Catholic institutions is scant, but there is some evidence that patient’s may be very surprised to learn of limitations [12,13]. A public opinion research poll of 1000 women conducted in 2000 found that the majority expected a full range of reproductive health services regardless of religious affiliation and 45% believed they would be able to obtain medical service that go against Catholic religious teachings [14]. Given that receiving care at a Catholic institution does not appear to be primarily motivated by patients’ religious beliefs, we wanted to test the hypothesis that women do not anticipate a difference in care when attending a Catholic medical institution.
2. Materials and methods We approached a convenience sample of women in the Denver area to assess expectations and preferences for family planning care. Reproductive aged women (18-45 years) who were able to read English or Spanish were eligible for participation. Women answering our online or printed advertisements were directed to a website where they completed a brief survey to determine eligibility. Eligible women were then randomized to read a vignette describing one of two clinical scenarios (Fig. 1). The scenarios were identical except for the name of the institution; one was a hypothetical Catholic hospital (St. Ignatius Hospital of Denver) and the other a hypothetical secular one (Metropolitan Hospital of Denver). Following display of each vignette, the participant completed a survey which asked if
the participant would expect to receive care for a comprehensive list of family planning services at the institution to which they were assigned, such as, “If I wanted, to go on “the pill” for birth control, I would expect that my OB/GYN at St. Ignatius/Metropolitan Hospital would prescribe it.” The participant was given the option of answering “yes,” “no,” or “I don’t know.” Secondarily, we assessed participants’ preferences for care using the same list of family planning services, specifying that the participant should indicate her personal preference and that she should no longer consider herself a patient of the theoretical vignette. For each service we asked where she would seek care using the answer selections of “my OB/GYN,” “my primary care provider (example: nurse practitioner, family doctor),” “a clinic like Planned Parenthood,” “Other- please specify,” or “I would never request this service.” Next, we assessed demographic, reproductive and gynecologic characteristics. Finally, we included an optional response box for open-ended comments after completion of the survey questions. We initially piloted the survey in-person to ten participants to assess readability and absence of ambiguity; based on this feedback, the survey was revised. We advertised the survey online with Craigslist and Facebook and placed fliers in multiple locations throughout the Denver Metropolitan area. Facebook advertisements were in English only, Craigslist advertisements and fliers were in English and Spanish. Participants who completed the survey received a $5 gift card to a local supermarket or coffee shop. Study data was collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at University of Colorado. REDCap is a secure, web-based application designed to support data capture for research studies. This publication was supported by NIH/NCRR
Fig. 1. Introductory scenarios given to participants based on randomization.
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Colorado CTSI Grant Number UL1 RR025780. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views. We hypothesized that women surveyed about routine gynecologic family planning care will have similar expectations whether the care is provided at a Catholic versus a secular institution. Our hypothesis assumed equivalent expectations for provision of non-abortion family planning between patients at Catholic and standard health care systems. We calculated the sample size using Blackwelder’s formula for equivalence: (Z 0.95 + Z 0.80) 2 [Ps(1-Ps) + Pn(1Pn)]/(Ps-Pn-D) 2, where Ps is the proportion of positive results in the standard group, Pn is the proportion in the novel group, and D represents the greatest difference that is considered equivalent. We estimated that 90% of patients given each clinical setting would expect their gynecologist to provide non-abortion contraceptive care, with D=0.1, α= 0.05, and power of 80%. The required sample size was 111 in each group, or 222 total participants. We aimed to recruit 240 to account for incomplete surveys. Summary statistics were used to describe the population and the outcomes. Means were compared using the Student’s t-test and proportions compared using the X 2 test, or Fisher’s exact test for small cell sizes. IBM SPSS Statistics (version 21.0.0) was used for all analyses. The study was approved by the Colorado Multiple Institutional Review Board (COMIRB).
3. Results After exclusion of incomplete surveys, a total of 236 surveys were completed between February 11 2013-May 16 2013 and included in our analysis; 115 were randomized to Metropolitan hospital, 121 to St. Ignatius hospital. Table 1 demonstrates participant characteristics. The majority of participants were young, white, non-Hispanic/Latino, single women who have never been pregnant. The most commonly identified religion was either agnostic/atheist/no religion and the majority had completed an undergraduate or graduate degree. Most of our participants reported having commercial insurance and receiving routine gynecologic care. Overall, characteristics were similar between groups. Seventy-four percent of our participants reported where they usually receive their gynecologic care: 30% went to an OB/GYN clinic, 16% to a non-GYN primary care clinic, 8% to Planned Parenthood, 6% to student health clinic, and 40% reported a clinic/hospital but did not specify if the type of care they received there was from an OB/GYN or other provider. Table 2 demonstrates participant responses to our questions about expectations for care. Regardless of institution type, the majority of participants expected that their gynecologist would provide the range of family planning care surveyed. Over 90% of participants expected to receive short and long-acting reversible contraceptive methods at either facility. Lower proportions of participants expected care for abortion care services at either institution.
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Table 1 Participant demographics Characteristic
Metropolitan St. Ignatius P-value Hospital of Denver Hospital of Denver (n=115) (n, %) (n=121) (n, %)
Age (Mean, [SD]) 27.2 (6.3) Race White 90 (78.3) American 1 (0.9) Indian/Alaskan Asian 3 (2.6) Black/African 4 (3.5) American N. Hawaiian/ 2 (1.7) Pacific Islander Other 15 (13) Ethnicity Hispanic/Latino 26 (22.6) Not 89 (77.4) Hispanic/Latino Marital status Single 72 (62.6) Married 36 (31.3) Separated/ 7 (6.1) divorced/other Ever pregnant 51 (44.3) Has given birth 35 (30.4) at least once Religion Catholic 28 (24.3) Christian/ 28 (24.3) Protestant Other religion 13 (11.3) Agnostic/Atheist/ 46 (40.0) No Religion Insurance Commercial 81 (70.4) Public 7 (6.1) (i.e.: Medicaid) Student 12 (10.4) No insurance 15 (13.0) Educational experience Less than 2 (1.8) high school High school 12 (10.8) degree/GED/ Vocational school Some college 33 (28.9) Undergraduate 35 (30.7) degree Graduate degree 32 (28.1) Receives routine 86 (76.1) gynecologic care
28.8 (6.8)
0.05 0.08
105 (86.8) 0 (0) 4 (3.3) 7 (5.8) 0 (0) 5 (4.1) 0.09 17 (14.0) 104 (86.0) 0.60 68 (56.2) 45 (37.2) 8 (6.6) 42 (34.7) 32 (26.4)
0.14 0.56 0.12
21 (17.6) 46 (38.7) 11 (9.2) 41 (34.5) 0.89 89 (73.6) 5 (4.1) 13 (10.7) 14 (11.6) 0.40 0 (0) 12 (9.9)
35 (28.9) 47 (38.8) 27 (22.3) 98 (81.0)
0.43
The only difference between expectations for family planning care by institution type was for natural family planning advice; participants given the hypothetical example of attending St. Ignatius were more likely to expect natural family planning advice (OR=7.4; 95% confidence interval 1.6, 33.7). (See Table 2.)
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Table 2 Participant responses for expectations for care Family planning method
Metropolitan Hospital of Denver (n=115) (n, %)
Natural family planning advice Yes No I don’t know Provide a diaphragm Yes No I don’t know Prescribe birth control pill Yes No I don’t know Provide Depo-provera® (the shot) Yes No I don’t know Get an intrauterine device (IUD) Yes No I don’t know Prescribe emergency contraception (Plan B® or morning after pill) Yes No I don’t know Perform sterilization (to get my tubes tied) Yes No I don’t know Provide treatment of a miscarriage (D&C) Yes No I don’t know End a pregnancy with a lethal abnormality (baby will not live more than one year if born) Yes No I don’t know End a pregnancy with a genetic abnormality (i.e. Downs syndrome) Yes No I don’t know End a normal pregnancy (for personal reasons) Yes No I don’t know
After ascertaining the care women expected at clinics at each institution, we asked participants where they would go for reproductive health care to assess the likelihood that women’s expectations of care will be met (Table 3). Over 80% of respondents chose their OB/GYN or PCP for all short or long-acting reversible contraceptive methods. “A clinic like Planned Parenthood” was chosen by 9-12%. If the participant needed a termination for a lethal abnormality, 66% expected to go to her OB/GYN or PCP for care. Fewer women, but still a majority, would go to their primary provider for emergency contraception (56%) and elective termination of pregnancy (50%).
St. Ignatius Hospital of Denver (n=121) (n, %)
P-value
b0.01 98 (86.0) 13 (11.4) 3 (2.6)
112 (93.3) 2 (1.7) 6 (5.0)
105 (91.3) 6 (5.2) 4 (3.5)
112 (93.3) 4 (3.3) 4 (3.3)
110 (95.7) 2 (1.7) 3 (2.6)
111 (92.5) 5 (4.2) 4 (3.3)
108 (94.7) 5 (4.4) 1 (0.9)
110 (90.9) 6 (5.0) 5 (4.1)
107 (93.9) 6 (5.3) 1 (0.9)
108 (90.0) 7 (5.8) 5 (4.2)
92 (81.4) 14 (12.4) 7 (6.2)
93 (78.2) 21 (17.6) 5 (4.2)
94 (82.5) 8 (7.0) 12 (10.5)
96 (80.0) 14 (11.7) 10 (8.3)
99 (86.8) 5 (4.4) 10 (8.8)
108 (91.5) 3 (2.5) 7 (5.9)
79 (68.7) 16 (13.9) 20 (17.4)
79 (65.3) 23 (19.0) 19 (15.7)
72 (63.7) 24 (21.2) 17 (15.0)
65 (54.2) 34 (28.3) 21 (17.5)
67 (58.3) 32 (27.8) 16 (13.9)
58 (47.9) 44 (36.4) 19 (15.7)
0.77
0.52
0.28
0.27
0.45
0.43
0.51
0.57
0.32
0.27
4. Discussion In this study, we randomly assigned a convenience sample of reproductive-aged women living in a major metropolitan area to answer questions about expected care at one of two hypothetical women’s health clinics: one at a Catholic hospital, and one at a secular institution. Our convenience sample is similar to Denver’s demographics. Demographic statistics from 2008-2012 demonstrate that the majorities are white (74%), not Hispanic/Latino (68%), and almost half have completed a bachelor’s degree or higher (48%) [15]. Forty-seven percent of Denver county habitants
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Table 3 Participants responses to where they would seek care based on family planning methods Family planning method
OB/ GYN
PCP
Family I would Other Planning Clinic never request
Advice about natural family planning methods (such as withdrawal or the rhythm method) A diaphragm for birth control To go on the pill for birth control Depo-provera (the shot) for birth control An intrauterine device (IUD) for birth control Emergency contraception (Plan B or the morning after pill) Sterilization (to get my tubes tied) Desired a D&C for a miscarriage End a pregnancy complicated by a lethal abnormality (baby will not live more than one year if born) End a pregnancy with a genetic abnormality (i.e. Downs syndrome) End a pregnancy (i.e. for personal reasons)
53.2% 62.0% 60.7% 60.7% 73.9% 40.7% 78.2% 80.9% 61.8% 51.9% 44.9%
19.6% 18.8% 25.2% 22.2% 12.8% 15.2% 12.4% 9.6% 4.3% 5.2% 4.7%
10.2% 12.0% 11.1% 9.4% 9.0% 29.0% 4.3% 7.4% 16.3% 17.6% 28.2%
14.9% 7.3% 3.0% 7.7% 4.3% 6.5% 4.3% 2.2% 16.3% 24.0% 21.8%
2.1% 0% 0% 0% 0% 8.7% 0.9% 0% 1.3% 1.3% 0.4%
OB/GYN: obstetrician/gynecologist, PCP: primary care physician.
do not affiliate with a religious congregation, similar to our finding that the majority of participants reported that they are agnostic/atheist/no religion [16]. Importantly, the majority of our participants were young, single women who have never been pregnant and therefore represent a population likely to access family planning services. We assessed expectations for family planning care and their setting preferences for reproductive health care. We hypothesized that women would have similar expectations despite defined policies limiting reproductive health care practices at Catholic health care facilities. We found that most women in our survey expect that their OB/GYN will provide the full range of family planning services, regardless of institution type. The majority also choose to seek care from their OB/GYN for most of the services surveyed. Unlike other services, almost one-third of participants selected Planned Parenthood as a place of care when the patient needed emergency contraception or an elective termination. This is consistent with Weitz and Cockrill’s report on patients presenting to abortion clinics across the US heartland; they found that the majority of these women sought abortion care at a free-standing clinic rather than from their general provider [17]. Our study findings have important public health implications. Many Catholic institutions limit reproductive healthcare options based on religious doctrines and these limitations have health repercussions [1–8]. At one Jesuit hospital, limitations on immediate postpartum contraception in the form of depot medroxyprogesterone acetate resulted in higher repeat pregnancy rates for adolescents and young adult women [2]. Two qualitative studies describe the experiences of physicians working in Catholic hospitals; many of the doctors were conflicted with the Catholic hospital polices that interfered with management of obstetrical emergencies such as incomplete abortion, molar pregnancies, and previable premature rupture of membranes as they were perceived by hospital authorities to require treatment in the form of abortion care [6,8]. Further the ethical and religious directives of Catholic hospitals directly prohibit abortion care and instruct Catholic health care
institutions “to be concerned about the danger of scandal in any association with abortion providers” [18]. Thus for women presenting to their PCP with the expectation of abortion care or a referral to an abortion provider, these directives will directly inhibit care and likely lead to greater delays and additional stigmatization. It appears that our cohort of women did not anticipate a difference in reproductive healthcare at a Catholic institution other than for natural family planning advice. Thus, women who seek care at religiously affiliated hospitals may not recognize that their healthcare options are influenced by religious doctrines. As Wall discusses, in the late nineteenth and early twentieth centuries, Catholic hospitals’ religious affiliations were more obvious as nuns attended to patients and the halls were filled with obvious religious paraphernalia; today’s hospitals are less reflective of religious ties and more reflective of general medical care [19]. If women who enroll at Catholic hospitals do not receive information related to potential healthcare restrictions, their ability to act as informed healthcare consumers may be constrained. This study has several limitations. Although the demographics of this convenience sample were comparable to Denver overall, and were similar between groups, it is possible that patients attending Catholic hospitals differ. Traditionally, Catholic hospitals were recognized for the increased care they provide to underserved and uninsured patients, who likely represent a cohort of women that may differ in terms of educational, financial, and religious demographics than our sample. Recently, however, reports demonstrate that Catholic hospitals and secular hospitals bill Medicare and Medicaid similarly, and most patients choose a hospital for reasons other than religiosity [1,9–11]. Further, use of a convenience sample has the inherent limitation of selection bias. This was a survey about a hypothetical situation that implied one secular hospital and one Catholic hospital. We chose to not explicitly label St. Ignatius a Catholic hospital in order to avoid emphasizing the primary objective of the study. When a patient actually enters a Catholic hospital she may have different expectations. Participants may have considered St. Ignatius to be a Christian rather than Catholic
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hospital, or even a secular hospital with a traditional religious name. Four Denver hospitals have religiously affiliated names: 3 are Catholic and one is secular. Thus, some participants may have attended this last hospital and not experienced restrictions to care; this may have impacted our results. As a greater proportion of our patients randomized to St. Ignatius expected counseling regarding natural family planning, however, it suggests that they considered it to be a Catholic hospital. Future research should query patients seeking well-women care at Catholic hospitals about expectations of family planning services; we received human subjects’ approval to conduct surveys at a secular and a Catholic hospital, but our attempts to receive institutional approval were ultimately unsuccessful. Our data provide a valuable contribution to local and national discussions of the rise of hospital mergers and employer-based insurance limitations on reimbursement for family planning services. Women expect and prefer contraceptive care from their own PCP or OB-GYN. Reliance on dedicated family planning clinics such as Planned Parenthood for primary preventative care such as contraception is common and reflects how these clinics have filled a gap in women’s healthcare. The Institute of Medicine outlines six performance expectations for the 21st century healthcare system: care must be safe, timely, effective, efficient, patient centered, and equitable. [20]. Deferring women’s healthcare needs at Catholic hospitals and associated institutions falls far short of these aims. References [1] Uttley L, Reynertson S, Kenny L, Melling L. Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat of Reproductive Health Care. New York, NY: The MergerWatch Project and the American Civil Liberties Union; 2013. [2] Guiahi M, McNulty M, Garbe G, Edwards S, Kenton K. Changing depot medroxyprogesterone acetate access at a faith-based institution. Contraception Sep 2011;84(3):280–4. [3] Polis C, Schaffer K, Harrison T. Accessibility of emergency contraception in California's Catholic hospitals. Women's health issues: official publication of the Jacobs Institute of Women's Health, 15. 4; 2005, pp. 174–8. [4] Harrison T. Availability of emergency contraception: a survey of hospital emergency department staff. Ann Emerg Med 2005;46 (2):105–10.
[5] Temin E, Coles T, Feldman JA, Mehta SD. Availability of emergency contraception in Massachusetts emergency departments. Acad Emerg Med 2005;12(10):987–93. [6] Freedman LR, Landy U, Steinauer J. When there's a heartbeat: miscarriage management in Catholic-owned hospitals. Am J Public Health Oct 2008;98(10):1774–8. [7] Stulberg DB, Dude AM Dahlquist I, Curlin FA. Obstetriciangynecologists, religious institutions, and conflicts regarding patientcare policies. Am J Obstet Gynecol 2012;207(1):73.e71–5. [8] Freedman LF, Stulberg DB. Conflicts in care for obstetric complications in Catholic hospitals. AJOB Primary Research, 4. 4; 2013, pp. 1–10. [9] Tu HLJ. Word of Mouth and Physician Referrals Still Drive Health Care Provider Choice. HSC Research Brief No. 9; 2008 [ http://www. hschange.com/CONTENT/1028/. Accessed 3/7/2014]. [10] Salisbury CJ. How do people choose their doctor? BMJ 1989;299 (6699):608–10. [11] Wun YT, Lam TP, Lam KF, Goldberg D, Li DK, Yip KC. How do patients choose their doctors for primary care in a free market? J Eval Clin Pract Dec 2010;16(6):1215–20. [12] Eckholm E. Bishops Sued Over Anti-Abortion Policies at Catholic Hospitals. The New York Times; 2013. [13] Raghavan R. A piece of my mind. A question of faith. JAMA 2007;297 (13):1412. [14] Russonello Belden, Stewart. Religion, Reproductive Health and Access to Services: A National Survey of Women. Washington, D.C. http://www.catholicsforchoice.org/topics/healthcare/documents/ 2000religionreproductivehealthandaccesstoservices.pdf2000. [15] United States Census Bureau, American Fact Finder. ACS Demographic and Housing Estimates 2008-2012, American Community Survey 5-Year Estimates. Available from: http://factfinder2.census. gov/faces/tableservices/jsf/pages/productview.xhtml? pid=ACS_12_5YR_DP05. [16] City-Data.com. Denver County, Colorado (CO) Religion Statistics Profile – Denver. Available from: http://www.city-data.com/county/ religion/Denver-County-CO.html. [17] Weitz TA, Cockrill K. Abortion clinic patients' opinions about obtaining abortions from general women's health care providers. Patient Educ Couns 2010;81(3):409–14. [18] United States Conference of Catholic Bishops. Ethical and religious directives for Catholic Health Care Services. Available from: http:// www.usccb.org/issues-and-action/human-life-and-dignity/health-care/ upload/Ethical-Religious-Directives-Catholic-Health-Care-Servicesfifth-edition-2009.pdf2009. [19] Wall BM. American Catholic Hospitals: A Century of Changing Markets and Missions. New Brunswick, New Jersey, and London: Rutgers University Press; 2011. [20] Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century; 2001.