June 26, 2014 — Summary of "Tubal Ligation in Catholic Hospitals: A Qualitative Study of Ob-Gyns' Experiences," Stulberg et al., Contraception, May 5, 2014.
Female sterilization is the second most common contraceptive method among U.S. women, but "tubal sterilization is not always available to women," often because of "system-level barriers," such as Catholic hospital policies that prohibit the procedure, according to a study led by Debra Stulberg of the University of Chicago's MacLean Center for Clinical Medical Ethics and departments of family medicine and obstetrics and gynecology. About half of the roughly 700,000 female sterilizations performed annually in the U.S. occur within 48 hours postpartum, they noted.
Meanwhile, the Roman Catholic Church has become "a large and growing stakeholder in the United States health care system," with one in six U.S. patients receiving care at a Catholic institution, the researchers wrote.
Although the church's directives for health care services prohibit sterilization at Catholic facilities, hospitals vary in how they interpret this order. Some Catholic hospitals permit sterilizations in limited circumstances or have created arrangements to allow patients to access otherwise prohibited services. The researchers developed a study to examine ob-gyns' experiences when patients seek sterilization services at Catholic hospitals.
The researchers contacted ob-gyns who worked in Catholic hospitals and participated in a previous survey on reproductive health care. They also recruited some ob-gyns from non-Catholic hospitals for comparison.
A qualitatively trained sociologist conducted 45-60 minute interviews that included guided but open-ended questions on topics such as the ob-gyns' likes and dislikes about their hospital; how their values aligned with those of their employers and peers; and clinical issues related to abortion, infertility and sterilization. The interviews were transcribed and thematically analyzed.
The researchers also collected respondents' demographic and religious characteristics.
The final sample included 31 ob-gyns -- 27 of whom had worked in Catholic hospitals -- from all regions of the U.S. Only one of the ob-gyns had never trained or worked in a non-Catholic hospital.
None of the respondents expressed moral objections to sterilization. They held diverse beliefs on abortion and religion, the study found.
The analysis of the interviews revealed two major themes, which the researchers summarized as "risk of harm to women" and "when workarounds don't work."
'Risk of Harm to Women'
The "risk of harm to women" theme included ob-gyns' concern "that their inability to provide tubal sterilization to women, due to the Catholic Directives, sometimes posed a risk of harm to those patients." For example, some patients had a contraindication to future pregnancy, or they were undergoing a medically necessary cesarean section and the ob-gyn was concerned that not performing "a concurrent tubal ligation would expose the patient to unnecessary risk with a second surgery," the researchers wrote.
Ob-gyns also expressed frustration with not being able to provide their patients with what they considered to be the standard of care and discomfort over denying sterilizations that they felt were in a patient's best interest.
'When Workarounds Do Not Work'
The other major theme -- "when workarounds do not work" -- encompassed ob-gyns' descriptions of "scenarios in which workarounds [to Catholic hospital bans on sterilization] were insufficient," the researchers wrote.
They noted that while ob-gyns cited some cases in which they were about to circumvent the bans, there were three types of circumstances in which those efforts were typically inadequate: "partial workarounds that did not apply to all women; workarounds that were narrowed due to changes in enforcement and workarounds subject to a patient's insurance or ability to pay."
The insufficient workarounds often involved sales of hospitals or parts of hospitals to Catholic entities, or increased involvement or stricter enforcement by local bishops. "[I]n some hospitals, physicians who had come to rely on workarounds, or who had been told they would be able to bypass the sterilization ban in specific scenarios, found these options no longer available for their patients," the researchers wrote.
Ob-gyns also described situations in which patients' insurance coverage only included a Catholic hospital, meaning that patients could not obtain tubal sterilization unless they secured special permission from the insurer to cover it at another hospital.
On the whole, the respondents "disagreed with strict Catholic hospital prohibitions on sterilization, especially when the patient faced increased medical risk from a future pregnancy or when she was undergoing cesarean delivery," the researchers wrote.
They noted various implications for health care providers, including the "repeated examples of tightening enforcement under new hospital management or a new bishop." The researchers advised health care providers seeking employment or privileges at Catholic hospitals to be wary of "any upfront assurance that sterilization" will be allowed in some cases. They also called for officials at non-Catholic hospital to "carefully consider" how a new Catholic affiliation could affect women's health care.
The researchers also highlighted the added barriers for women with insurance and financial limitations. In addition, they noted that their "findings have important implications for patient autonomy and outcomes." They note that women typically do not have the necessary information "to make an informed choice about whether to seek care in a Catholic hospital" and likely do not "choose their hospital based upon its religious affiliation."
Thus, "women should be encouraged to ask questions in advance to maximize their opportunities for receiving desired sterilization," the researchers wrote. They concluded that as Catholic involvement in the U.S. health care system continues to expand, "policymakers should address whether public funding of medical care should be subject to religious directives that may not be in the patient's best interest."