The rapid growth of Catholic-affiliated hospitals in the U.S. could significantly reduce access to inpatient sterilization procedures, according to a new study that examines the rising influence of religion on reproductive health services.

The study, published by the National Bureau of Economic Research, estimates that Catholic hospitals reduce the per-bed annual rates of inpatient abortions by 30 percent, and tubal ligations, or sterilization, by 31 percent.

Those impacts are being magnified by rapid consolidation among hospitals nationwide, a trend that resulted in a 22 percent increase in Catholic-sponsored or Catholic-affiliated hospitals between 2001 and 2016. The study found that the restrictions on reproductive health services at those facilities translates to more than 9,500 fewer tubal ligations per year.

“This alone represents a substantial cost to women, who must subsequently rely on other, more inconvenient suboptimal forms of contraception,” the study concluded.

The finding comes amid increasing debate over the influence of Catholic doctrine on access to reproductive health services. The church’s restrictions have created flashpoints across the country, including a lawsuit filed by the American Civil Liberties Union on behalf of a Michigan woman who said she was repeatedly refused appropriate care — the surgical removal of a fetus — after experiencing a miscarriage at 18 weeks.

The United States Conference of Catholic Bishops, which enforces directives that prohibit sterilization, abortion, and contraceptive services at Catholic hospitals, did not respond to a request for comment.

The study found Catholic affiliation at hospitals did not result in a statistically significant increase in complications from miscarriages or sterilization procedures, nor did it affect the number of caesarean sections performed. The study also examined vasectomies, but turned up limited data on that procedure because it is typically performed on an outpatient basis.

Lack of access

The consolidation of Catholic hospitals has increased the likelihood of conflict over the church’s restrictions, because in many communities a Catholic hospital is the most convenient option, and sometimes it’s the only option.

By 2016, the study found, 14.5 percent of all U.S. acute care hospitals were Catholic, including 10 of the 25 largest health care systems in the country. In some states with fewer hospitals, Catholic providers are a dominant presence in the market. In five states (Alaska, Iowa, Washington, Wisconsin, and South Dakota), more than 40 percent of acute care beds were Catholic-owned or -affiliated in 2016.

The study found the Catholic affiliation consistently reduces the number of inpatient abortions and tubal ligations performed at hospitals. Abortions are more often provided as an outpatient procedure, so the effect on access is less pronounced. But the restrictions on tubal ligations could impair access, especially among populations that lack the time and resources to travel to another hospital to have the procedure performed.

“Most public health professionals believe that access to reproductive care, and in particular tubal ligations, is one of the many options for helping to reduce unwanted pregnancy in this country,” said Elaine Hill, a co-author of the study who is a professor of health economics at the University of Rochester School of Medicine and Dentistry. “Policies addressing the ways in which religious ownership of hospitals might impede access could be very beneficial to the population of women affected.”

Uneven effects

The Catholic restrictions on reproductive care impact racial groups unevenly, according to the study, which found that black and Hispanic women are disproportionately affected by the restrictions on tubal ligations.

The study used data from the American Hospital Association’s Annual Survey and the Healthcare Cost and Utilization Project to examine changes in ownership and estimate the impact of Catholic policies on the reproductive procedures performed by hospitals. The researchers reviewed data from six high-population states: Arizona, Florida, New Jersey, California, New York, and Washington.

The study noted that Catholic restrictions on reproductive care are not always followed, otherwise the reduction in abortions and sterilizations at these hospitals would be 100 percent, not 30 and 31 percent, respectively. A prior study found physicians intentionally violated Catholic care protocols when they believed the safety of the patient was being compromised.

Republished with permission from STAT. This article originally appeared on September 14, 2017