Postpartum LARC: Highly Effective, but Restricted by Some Hospitals
EXECUTIVE SUMMARY
Women who receive care in Catholic facilities may be denied postpartum long-acting reversible contraception due to religious directives that ban such care.
• Refusal to offer contraceptive care stems from the Ethical and Religious Directives, a set of rules written by the U.S. Conference of Catholic Bishops. The rules bar Catholic hospitals from providing procedures the church deems immoral, such as abortions, contraception, and sterilization, except in extreme situations.
• According to a 2016 report, 548 hospitals — 14.5 % of all U.S. short-term care facilities — are urged to follow these directives. These hospitals are owned by a Catholic health system or diocese, affiliated with a Catholic hospital or system through a business partnership, or are historically Catholic hospitals owned by a secular nonprofit or for-profit healthcare system.
A new mother is seeking a long-acting reversible contraceptive (LARC) method. When asked why she did not seek immediate placement of an intrauterine device (IUD) following her delivery, she says that the hospital where she gave birth prohibited such practices.
Women who receive care in Catholic facilities may be denied postpartum LARC due to religious directives that ban such care. In 10 states, more than 30% of all hospital beds are in Catholic facilities. In about 50% of states, more than one in five hospital beds is in a Catholic facility.1
Refusal to offer postpartum LARC methods stems from the Ethical and Religious Directives, a set of rules written by the U.S. Conference of Catholic Bishops. The directives urge Catholic hospitals not to provide procedures and services the church deems immoral, such as abortions, contraception, and sterilization, with very few exceptions.
According to a 2016 report published by the American Civil Liberties Union, 548 hospitals — 14.5% of all U.S. short-term care facilities — are urged to follow these directives, a 22% increase since 2001. These hospitals are owned by a Catholic health system or diocese, affiliated with a Catholic hospital or system through a business partnership, or are historically Catholic hospitals owned by a secular nonprofit or for-profit healthcare system.1
Government protections that allow religious hospitals to restrict care are limiting access to healthcare consumers, says Maryam Guiahi, MD, MSc, associate professor of obstetrics and gynecology at University of Colorado Denver School of Medicine. Guiahi is the author of a recent commentary on the subject.2
Many women once faced financial barriers to LARC access, such as lack of insurance coverage or high out-of-pocket costs. The Affordable Care Act in 2012 instructed insurers to provide contraceptives without copays, leading to an increase in LARC use.3
Until 2012, most state Medicaid programs provided a single, bundled payment for all care during the delivery hospitalization.4 Since this episode payment did not increase to cover the cost of immediate postpartum LARC-related care, providers were unable to receive separate payment for device placement in the inpatient setting. However, as of February 2018, 37 state Medicaid programs can bill separately for immediate postpartum LARC.5
Catholic hospitals may not choose to allow immediate postpartum LARC placement due to religious directives. According to information from the Wisconsin Hospital Association, one Catholic hospital, Ascension St. Joseph Hospital, billed for an IUD nine times for the fiscal year ending June 2019. Less than five miles away, a non-Catholic institution, Froedtert Memorial Lutheran Hospital, billed for more than 1,500 placements in the same time period.6
What can reproductive health providers do to help women get the reproductive healthcare they need in light of current directives governing Catholic hospitals?
“Reproductive providers in Catholic settings who are interested in providing appropriate options should consider several efforts when faced with this ethical dilemma,” says Guiahi. “First, they should work toward improved efforts at transparency to help avoid conflicts in care and support patient autonomy.”
For example, when patients call to request birth control appointments, Guiahi suggests they should be informed ahead of time of any relevant restrictions to care. Secondly, clinicians unable to provide this care should offer direct referrals for nearby providers who can deliver services that patients need or desire.
“Finally, they should work with their institutions to recognize when reproductive services are medically indicated, and create local policies that support provision,” states Guiahi. “Many local ethicists are open to the medical considerations of reproductive experts in these settings.”
Medical evidence backs the safety and efficacy of immediate postpartum LARC methods. The CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use classifies immediate postpartum use of IUDs and implants as Category 1 (no restriction for use) or Category 2 (advantages generally outweigh theoretical or proven risks).7
REFERENCES
- American Civil Liberties Union. Health care denied: Patients and physicians speak out about Catholic hospitals and threat to women’s health and lives. New York City; 2016. Available at: https://bit.ly/2vghkdD.
- Guiahi M. Religious refusals to long-acting reversible contraceptives in Catholic settings: A call for evidence. Am J Obstet Gynecol 2019; doi: 10.1016/j.ajog.2019.11.1270.
- Snyder AH, Weisman CS, Liu G, et al. The impact of the Affordable Care Act on contraceptive use and costs among privately insured women. Womens Health Issues 2018;28:219-223.
- Moniz MH, Spector-Bagdady K, Heisler M, et al. Inpatient postpartum long-acting reversible contraception: Care that promotes reproductive justice. Obstet Gynecol 2017;130:783-787.
- Steenland MW, Pace LE, Sinaiko AD, et al. Association between South Carolina Medicaid’s change in payment for immediate postpartum long-acting reversible contraception and birth intervals. JAMA 2019;322:76-78.
- Rani RS. Wisconsin’s Catholic hospitals limit reproductive procedures. The Washington Post, Dec. 21, 2019. Available at: https://wapo.st/36PYZBX.
- Centers for Disease Control and Prevention. Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep 2011;60:878-883.
Women who receive care in Catholic facilities may be denied postpartum LARC due to religious directives that ban such care. In 10 states, more than 30% of all hospital beds are in Catholic facilities. In about 50% of states, more than one in five hospital beds is in a Catholic facility.
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