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Religious refusals to long-acting reversible contraceptives in Catholic settings: a call for evidence

Published:December 02, 2019DOI:https://doi.org/10.1016/j.ajog.2019.11.1270
      No-cost contraceptive provisions as in the Affordable Care Act have substantially reduced the financial burdens that patients previously faced with long-acting reversible contraception (LARC) access. Such efforts have contributed to improved LARC uptake and substantial declines in unintended pregnancy and abortion rates. However, governmental protections that allow religious restrictions to care to be implemented at institutional and systemic levels currently limit equitable access by healthcare consumers. A significant proportion of the US healthcare market is controlled by Catholic healthcare systems, which use moral teachings to inform guidelines to care. Many patients do not realize that their healthcare choices will be affected by attendance at a Catholic institution, in part because such facilities do little to inform patients of restrictions to common reproductive services including LARC. Limited data demonstrate that often hormonal intrauterine devices are provided through workarounds, but that implants and copper intrauterine devices are rarely available or approved in Catholic settings. The scarcity of data, particularly on patient outcomes, is in part explained by research barriers within Catholic settings. This Call for Action sets forth the notion that we should no longer remain complicit with allowances for institutional religious refusals of care unless we understand medical and ethical outcomes.

      Key words

      THE PROBLEM: Catholic healthcare systems place religious barriers to the provision of long-acting reversible contraceptives, which threaten patient autonomy, justice, and provider well-being, and likely lead to adverse healthcare outcomes.
      THE SOLUTION: We must seek and demand an improved understanding of the impact of institutional religious restrictions on highly effective long-acting reversible contraceptives in Catholic settings, by studying patient and provider outcomes.
      Long-acting reversible contraceptive (LARC) methods, including implants and intrauterine devices (IUDs), are highly effective and provide a number of medical, social, and economic benefits. Previously, a major barrier to LARC access was financial, as many patients had inadequate insurance coverage or faced high upfront out-of-pocket costs. In 2012, the Affordable Care Act (ACA) implemented a contraception mandate that requires all insurance plans to provide contraceptives without high deductibles or copays. Dramatic reductions in out-of-pocket costs
      • Bearak J.M.
      • Finer L.B.
      • Jerman J.
      • Kavanaugh M.L.
      Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries.
      • Law A.
      • Wen L.
      • Lin J.
      • Tangirala M.
      • Schwartz J.S.
      • Zampaglione E.
      Are women benefiting from the Affordable Care Act? A real-world evaluation of the impact of the Affordable Care Act on out-of-pocket costs for contraceptives.
      • Becker N.V.
      • Polsky D.
      Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.
      and substantial increases in LARC uptake have since occurred.
      • Daniels K.
      • Daugherty J.
      • Jones J.
      • Mosher W.
      Current contraceptive use and variation by selected characteristics among women aged 15-44: United States, 2011-2013.
      ,
      • Carlin C.S.
      • Fertig A.R.
      • Dowd B.E.
      Affordable Care Act's mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage.
      Like other no-cost contraceptive provision initiatives in Colorado and Missouri,
      • Ricketts S.
      • Klingler G.
      • Schwalberg R.
      Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.
      ,
      • Secura G.M.
      • Madden T.
      • McNicholas C.
      • et al.
      Provision of no-cost, long-acting contraception and teenage pregnancy.
      further reductions in unintended pregnancy and abortion rates in the United States are expected to be attributed to ACA. Yet, although cost as a barrier has been substantially reduced, ongoing systemic LARC barriers have surfaced.
      Many patients receive care within Catholic healthcare facilities; as of 2016, 14.5% of US hospitals were Catholic owned or affiliated, accounting for 1 in 6 hospital beds,
      Growth of Catholic hospitals and health systems: 2016 update of the Miscarriage of Medicine Report.
      ,
      Catholic Health Care in the United States.
      and 349 of the 654 Catholic hospitals had obstetric services accounting for more than 529,000 deliveries.
      Catholic Health Care in the United States.
      The proportion of patients attending Catholic facilities will likely continue to increase; between 2001 and 2016, the number of Catholic acute care hospitals grew by 22%.
      Growth of Catholic hospitals and health systems: 2016 update of the Miscarriage of Medicine Report.
      For some patients, Catholic facilities are the only reasonable source of medical care; as of 2016, a total of 46 Catholic hospitals were designated as “sole community provider hospitals” based on their remote locations and lack of proximity to other major medical centers.
      Growth of Catholic hospitals and health systems: 2016 update of the Miscarriage of Medicine Report.
      Although most insured patients attending Catholic facilities have insurance coverage for LARC methods, governmental protections for religious organizations often nullify this coverage and limit equitable access. Specific to ACA, organizations that claim religious or moral beliefs may be deemed exempt from contraceptive coverage. Governmental conscience protections also extend the right of health facilities to invoke their “institutional conscience” as reasoning for objections to care.
      Department of Health and Human Services Department, Office of the Secretary. Protecting Statutory Conscience Rights in Health Care; Delegations of Authority.
      Within Catholic-owned or -affiliated health facilities, the Ethical and Religious Directives for Catholic Health Care Services (hereafter “the directives”) provide institutional rules created by the US Conference of Catholic Bishops to govern clinical care.
      US Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services.
      The directives place limitations on reproductive care based on concerns for dignity of life, which the church currently defines as beginning at the time of conception, and also based on moral teachings. Humanae Vitae, an encyclical letter written by Pope Paul VI in 1968, dictates that sexual intercourse (“the conjugal act”) should occur only when a husband and wife have both “love-giving” and “life-giving” intentions. Although this eliminates any contraceptive method, the directives allow heterosexual married couples to receive natural family planning instruction.
      US Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services.
      Notably, the church strictly prohibits copper IUDs based on its designation as an abortifacient, despite lack of scientific evidence.
      • Rivera R.
      • Yacobson I.
      • Grimes D.
      The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices.
      Furthermore, the directives cite concerns over the danger of “scandal,” defined as “an attitude or behavior which leads another to do evil,” raising concerns that contraceptive referrals are morally illicit.
      US Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services.
      Moral reasoning supports the notion that contraceptives can be used as medical therapies for noncontraceptive indications when all 4 conditions of the “double effect principle” are met (Table 1).
      • Furton E.J.
      • Cataldo P.J.
      Catholic Health Care Ethics: A Manual for Practitioners.
      Table 1 demonstrates these principles and contextualizes them with respect to the levonorgestrel IUD Mirena (Bayer, Whippany, NJ), which has US Food and Drug Administration approval for heavy menstrual bleeding. In contrast, implants and copper IUDs are less likely to be deemed appropriate, as noncontraceptive uses are off-label. Obstetrician−gynecologists in Catholic settings have confirmed that hormonal IUDs are often available, but that implants and copper IUDs are rarely, if ever, stocked or on formularies.
      • Guiahi M.
      • Hoover J.
      • Swartz M.
      • Teal S.
      Impact of Catholic hospital affiliation during obstetrics and gynecology residency on the provision of family planning.
      ,
      • Guiahi M.
      • Teal S.
      • Kenton K.
      • DeCesare J.
      • Steinauer J.
      Family planning training at Catholic and other religious hospitals: a national survey.
      Many obstetrician−gynecologists have reported the use of noncontraceptive indications as a workaround, whereby they directly elicit or exaggerate indications to help patients gain contraceptive access.
      • Guiahi M.
      • Hoover J.
      • Swartz M.
      • Teal S.
      Impact of Catholic hospital affiliation during obstetrics and gynecology residency on the provision of family planning.
      ,
      • Guiahi M.
      • Teal S.
      • Kenton K.
      • DeCesare J.
      • Steinauer J.
      Family planning training at Catholic and other religious hospitals: a national survey.
      Table 1The “double effect principle” conditions relevant to levonogestrel intrauterine device (IUD) for the noncontraceptive indication of heavy menstrual bleeding
      Double effect principle conditions
      • Furton E.J.
      • Cataldo P.J.
      Catholic Health Care Ethics: A Manual for Practitioners.
      Condition contextualized with respect to use of levonogestrel IUD for heavy menstrual bleeding
      #1: The action in itself, and considered in its object, is good or at least indifferent (that is, neither good nor bad)The use of hormonal IUD to reduce bleeding symptoms in a woman with heavy menstrual periods is a good action
      #2: The good effect and not the bad effect is intendedThe good effect of improving heavy menstrual bleeding is intended, not the “bad” effect of contraception
      #3: The good effect is not produced by means of the bad effectThe good effect of controlling bleeding is not secondary to the contraceptive effect (eg, the ends are not used to justify the means)
      #4: There is proportionately grave reason for permitting the bad effectWithout the hormnal IUD, a patient can experience heavy menstrual bleeding leading to significant anemia and even blood transfusions, which significantly impairs her health and well-being
      Guiahi. Religious refusals to LARC in Catholic settings. Am J Obstet Gynecol 2020.
      Complicating our understanding of how religious institutional restrictions to care influence patients is the finding that adherence to the directives varies across institutions.
      • Thorne N.B.
      • Soderborg T.K.
      • Glover J.J.
      • Hoffecker L.
      • Guiahi M.
      Reproductive health care in Catholic facilities: a scoping review.
      Mergers between Catholic and non-Catholic facilities have often allowed ongoing provision of certain contraceptives to ensure merger success.
      • Thorne N.B.
      • Soderborg T.K.
      • Glover J.J.
      • Hoffecker L.
      • Guiahi M.
      Reproductive health care in Catholic facilities: a scoping review.
      In some institutions, more permissive cultures allow broader use of noncontraceptive indications as a workaround, and some simply turn a blind eye to routine LARC provision for contraceptive indications.
      • Guiahi M.
      • Teal S.
      • Kenton K.
      • DeCesare J.
      • Steinauer J.
      Family planning training at Catholic and other religious hospitals: a national survey.
      Even though all facilities affiliated with Catholic systems are expected to adhere to the directives, specific ownership often plays a role; in a mystery-caller study conducted in 2014, of 144 US gynecology clinics found on Catholic hospital websites, only 4% of Catholic-owned clinics were able to schedule a copper IUD appointment compared to 97% of Catholic-affiliated clinics.
      • Guiahi M.
      • Teal S.B.
      • 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.
      Although many presume or argue that self-selection occurs, whereby only patients who agree with the church’s teaching choose related facilities, a recent national survey found that only 6.4% of consumers consider religious affiliation when selecting a health facility.
      • Guiahi M.
      • Helbin P.E.
      • Teal S.B.
      • Stulberg D.
      • Sheeder J.
      Patient views on religious institutional health care.
      Most do not anticipate that Catholic affiliation may mean family planning restrictions; a 2013 online survey found that expectations for receiving an IUD were similar at secular versus Catholic obstetric/gynecology clinics (93.9% [secular] vs. 90.0% [Catholic], P = .27).
      • Guiahi M.
      • Sheeder J.
      • Teal S.
      Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women's expectations and preferences for family planning care.
      Even when patients recognize implications for care, many who have attended a Catholic hospital did not recognize its religious affiliation.
      • Wascher J.M.
      • Hebert L.E.
      • Freedman L.R.
      • Stulberg D.B.
      Do women know whether their hospital is Catholic? Results from a national survey.
      Complicating and contributing to this misunderstanding is the finding that facilities lack transparency about their Catholic identity; in a recent website review of all 646 US Catholic hospitals, 21% did not report their Catholic identity, and only 28% specified influences on patient care.
      • Takahashi J.
      • Cher A.
      • Sheeder J.
      • Teal S.
      • Guiahi M.
      Disclosure of religious identity and health care practices on Catholic hospital websites.
      These findings raise several ethical concerns. Patient autonomy is violated not only because they are unable to receive the care they want or need, but because patients are not given the opportunity to avoid conflicts in care by being informed ahead of time about LARC restrictions.
      • Guiahi M.
      Catholic health care and women's health.
      In a prior mystery-caller study of gynecology clinics found on Catholic hospital websites, 95% were willing to schedule a birth control appointment, yet only with prompting did 32% report that copper IUDs were not allowed.
      • Guiahi M.
      • Teal S.B.
      • 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.
      Notably, Catholic obstetrician−gynecologists who adhere to the directives in practice believe that pre-visit transparency about contraceptive practices should be used to avoid conflicts in care and to support autonomy.
      • Marchin A.
      • Seale R.
      • Sheeder J.
      • Teal S.
      • Guiahi M.
      Integration of medical ethics and Catholic values in the provision of family planning services: a qualitative study.
      Advocates of Catholic healthcare have also cited the need for facilities to be more upfront and transparent about their Catholic identity and restrictions, with the understanding that even if patients are put off, there is no reason for Catholic institutions to be ashamed of their values.
      • Bouchard C.E.
      Sponsors are called to be prophets and reformers.
      Concerns for justice also exist, as many physicians believe that restrictions to care have the greatest impact on vulnerable populations, including low-income women, minorities, and those in rural settings.
      • Thorne N.B.
      • Soderborg T.K.
      • Glover J.J.
      • Hoffecker L.
      • Guiahi M.
      Reproductive health care in Catholic facilities: a scoping review.
      A recent analysis of public insurance enrollment data in Illinois found that black/Hispanic reproductive-aged women are more likely than their white peers to be enrolled in Medicaid managed care plans with a higher percentage of Catholic hospitals.
      • Gieseker R.
      • Garcia-Ricketts S.
      • Hasselbacher L.
      • Stulberg D.
      Family planning service provision in Illinois religious hospitals: racial/ethnic variation in access to non-religious hospitals for publicly insured women.
      Although many cite the Catholic Church’s history of providing care to underserved populations, institutional contraceptive restrictions likely further compound already existing health disparities.
      • Guiahi M.
      • McNulty M.
      • Garbe G.
      • Edwards S.
      • Kenton K.
      Changing depot medroxyprogesterone acetate access at a faith-based institution.
      Physicians in Catholic settings have reported conflicts, especially when medically indicated services are denied.
      • Thorne N.B.
      • Soderborg T.K.
      • Glover J.J.
      • Hoffecker L.
      • Guiahi M.
      Reproductive health care in Catholic facilities: a scoping review.
      Moral distress is a paradigm based on when a provider “knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”
      • Jameton A.
      Nursing Practice: The Ethical Issues.
      ; Catholic institutions serve as a natural environment to study this phenomenon. I personally experienced moral distress when working in a Catholic institution. Whereas providers who feel moral conflicts with providing services in secular settings may use conscientious objections to care to relieve such distress, I was left with the options of remaining compliant or risking employment violations. Although workarounds help certain patients to gain LARC access and at times provided me and probably others with moral relief, a healthcare system that relies on workarounds is an ineffective and potentially dangerous one.
      Recently, the US Department of Health and Human Services and the Office of Civil Rights have attempted to set forth broader conscience protections allowing institutions and individuals to invoke moral or religious claims as justifications for objections to care.
      Department of Health and Human Services Department, Office of the Secretary. Protecting Statutory Conscience Rights in Health Care; Delegations of Authority.
      Such protections conflict with the beliefs of most healthcare consumers (71.4%), who believe that their health choices should take priority over an institution’s religious affiliation.
      • Guiahi M.
      • Helbin P.E.
      • Teal S.B.
      • Stulberg D.
      • Sheeder J.
      Patient views on religious institutional health care.
      The implications of such protections and the prioritization of “institutional conscience” over providers’ own deeply held beliefs about providing effective preventive medical care such as LARC must be understood. In doing so, the need for conscientious provision protections can be better realized, and advocacy efforts may ensue.
      The public health benefits of LARC cannot be disputed, yet documentation of the impact of LARC restrictions in Catholic settings is limited. In a recent scoping review, I found only 27 studies on the broad topic of reproductive healthcare in Catholic settings, of which few addressed LARC.
      • Marchin A.
      • Seale R.
      • Sheeder J.
      • Teal S.
      • Guiahi M.
      Integration of medical ethics and Catholic values in the provision of family planning services: a qualitative study.
      Only one study examined patient outcomes and demonstrated that a restriction to injectable contraception during the immediate postpartum period resulted in higher rates of short-interval pregnancies.
      • Guiahi M.
      • McNulty M.
      • Garbe G.
      • Edwards S.
      • Kenton K.
      Changing depot medroxyprogesterone acetate access at a faith-based institution.
      My own efforts otherwise and those of others to study real-life outcomes in Catholic settings (eg, whether patients who receive LARC referrals from Catholic settings actually obtain LARC methods) have been met with resistance and dismissal. Many ethicists have explained to me the need to adhere to the directives as justification for research refusals, despite acknowledgement that nonadherence occurs in their settings. Such research refusals have also incited fears in employees of employment violations, or that workarounds that provide services to their patients may come under fire if documented. The ethicality of dismissing research efforts that document real-life provision of reproductive healthcare in these settings remains to be determined and adds to my concerns over lack of transparency and, frankly, dishonesty from Catholic institutions.
      Most obstetrician−gynecologists, including those that choose to work in Catholic settings
      • Guiahi M.
      • Hoover J.
      • Swartz M.
      • Teal S.
      Impact of Catholic hospital affiliation during obstetrics and gynecology residency on the provision of family planning.
      ,
      • Guiahi M.
      • Teal S.
      • Kenton K.
      • DeCesare J.
      • Steinauer J.
      Family planning training at Catholic and other religious hospitals: a national survey.
      as well as Catholic ones who work in other settings,
      • Marchin A.
      • Seale R.
      • Sheeder J.
      • Teal S.
      • Guiahi M.
      Integration of medical ethics and Catholic values in the provision of family planning services: a qualitative study.
      recognize the range of benefits that LARC methods provide
      • Lawrence R.E.
      • Rasinski K.A.
      • Yoon J.D.
      • Curlin F.A.
      Obstetrician-gynecologists’ views on contraception and natural family planning: a national survey.
      and the inherent issues that arise when LARC restrictions are enforced in Catholic settings. Yet many feel overpowered by the influences of the Catholic church and the government, despite being the very experts of contraceptive care. As healthcare providers, we can no longer remain complicit and let organizations and relevant stakeholders claim no harm based on lack of substantial evidence.
      Department of Health and Human Services Department, Office of the Secretary. Protecting Statutory Conscience Rights in Health Care; Delegations of Authority.
      Given the recent growth of Catholic health systems and growing governmental conscience protections for religious refusals, there is a critical need to support research efforts. We must demand that research efforts within Catholic institutions be ethical and expanded in order to understand the ways in which restrictions affect patients, the extent to which workarounds compensate, and whether certain populations are at greater risk for adverse outcomes compared to others. As this may prove difficult, we need more researchers and grant-funding mechanisms to target this complex intersection between religion and medicine, including government organizations such as the National Institutes of Health, which should be willing to study the impact of their protections on patients. In providing evidence of the real-life implications of institutional restrictions to LARC in Catholic settings, we can then inform advocacy efforts to ensure equitable access to effective healthcare.

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