Racial and ethnic disparities in short interval pregnancy following delivery in Catholic vs non-Catholic hospitals among California Medicaid enrollees.

OBJECTIVES: We examined the impact of Catholic hospital delivery on short interval pregnancy in the California 2010-2014 Medicaid population. STUDY DESIGN: We used Cox regression to estimate the association between hospital affiliation and short interval pregnancy, adjusting for patient factors. RESULTS: Catholic hospital delivery had increased the risk of pregnancy within 6 months for Black (hazard ratio [HR] 1.11, 95% CI 1.06, 1.17) and Hispanic (HR 1.07, 95% CI 1.05, 1.09) but not for White women (HR 1.02, 95% CI 0.98, 1.05). CONCLUSIONS: Among California women with Medicaid, Catholic hospital delivery was associated with short interval pregnancy only among women of color.

Preconception care utilization: Self-report versus claims-based measures among women with Medicaid.

The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.

Barriers to abortion provision in primary care in New England, 2019-2020: A qualitative study.

OBJECTIVE: To assess barriers to and facilitators of abortion provision among abortion-trained primary care providers. STUDY DESIGN: We conducted 21 qualitative in-depth interviews with 20 abortion-trained family physicians and one internal medicine physician in five New England states. We dual-coded interviews, using a consensus method to agree upon final coding schema. Through iterative dialogue, using an inductive content analysis approach, we synthesized the themes and identified patterns within each domain of inquiry. RESULTS: The most commonly reported barriers were a lack of organizational support, the Hyde Amendment, which prevents the use of federal funds for most abortion care, and the mifepristone Risk Evaluation and Mitigation Strategy, a federal regulation which prohibits routine mifepristone pharmacy dispensing. The logistical barriers created by these policies require cooperation from additional stakeholders, creating more opportunities for abortion stigma and moral opposition to arise. Other salient barriers included inter-specialty tension (particularly with obstetrician-gynecologists), perceived need for pre-abortion ultrasound, absence of a clinician support network, and lack of knowledge of existing resources for establishing abortion care in primary care. CONCLUSIONS: Increased abortion provision in primary care is one of many necessary responses to the human rights crisis produced by the Dobbs decision. Eliminating the Hyde Amendment and ending federal regulations restricting pharmacy dispensing of mifepristone are key interventions to address barriers to primary care abortion provision. Building interspecialty partnerships between family medicine and OB/GYN and spreading awareness of the evidence-based ultrasound-as-needed protocol and other educational resources are also likely to increase primary care abortion access. IMPLICATIONS: By exploring barriers to and facilitators of primary care abortion provision, this study outlines a targeted approach to support increased access to abortions. In states with legal abortion post-Roe, it is important that motivated and trained primary care providers can offer abortions, rather than referring patients to overburdened specialty clinics.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool.

Background: One Key Question® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings. Methods: We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR). Main Findings: Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments. Conclusions: The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788.

Preconception care and severe maternal morbidity in the United States.

BACKGROUND: In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE: Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN: This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS: Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS: Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.

Reproductive healthcare denials among a privately insured population.

This study aimed to quantify and examine reproductive healthcare denials experienced by individuals receiving employer-sponsored health insurance. We conducted a national cross-sectional survey using probability and non-probability-based panels from December 2019-January 2020. Eligible respondents were adults employed by any Standard and Poor's 500 company, who received employer-sponsored health insurance. Respondents (n = 1,001) reported whether anyone on their healthcare plan had been denied a reproductive healthcare service in the past five years and details about their denials. We conducted bivariate analyses and multiple logistic regression to estimate factors associated with denials. Eleven percent of respondents (14% of women; 10% of men) reported a denial. Compared to lower-income respondents, those with income ≥ $50,000/year were less likely to experience a denial (aOR = 0.53; 95% CI 0.29-0.97). Compared to respondents who were never married, being married (aOR = 2.33; 95% CI: 1.03-5.30) or cohabiting (aOR = 2.43; 95% CI: 1.03-5.72) significantly increased odds of experiencing a denial. In 38% of cases the patient learned of the denial at a scheduled visit, while 23% learned in an emergency setting, and 13% after the encounter. Individuals covered by employer-sponsored health insurance continue to be denied coverage of preventive services. Employers and insurers can facilitate access to reproductive healthcare by ensuring that their plans include comprehensive coverage and in-network providers offer comprehensive services.

Expectations about availability of contraception and abortion at a hypothetical Catholic hospital: Rural-urban disparities among Wisconsin women.

OBJECTIVE: To examine rural-urban differences in reproductive-aged Wisconsin women's expectations for contraceptive and abortion care at a hypothetical Catholic hospital. STUDY DESIGN: Between October 2019 and April 2020, we fielded a 2-stage, cross-sectional survey to Wisconsin women aged 18 to 45, oversampling rural census tracts and rural counties served by Catholic sole community hospitals. We presented a vignette about a hypothetical Catholic-named hospital; among participants perceiving it as Catholic, we conducted multivariable analyses predicting expectations for contraceptive services (birth control pills, Depo-Provera, intrauterine device or implant, tubal ligation) and abortion in the case of serious fetal indications. RESULTS: The response rate was 37.6% for the screener and 83.4% for the survey (N = 675). Among respondents (N = 376) perceiving the hospital as Catholic, expecting the full range of contraceptive methods was more common among rural (70.9%) vs urban (46.7%) participants (adjusted odds ratio = 3.99, 95% confidence interval: 1.99-7.99). In adjusted models, odds of expecting each contraceptive method were at least 3 times greater among rural vs urban participants. About one-third expected provision of abortion for serious fetal indications, with no difference by rurality (p > 0.05). CONCLUSIONS: In Wisconsin, rural women were more likely than urban women to expect a hypothetical Catholic hospital to provide the full range of contraceptive methods as well as each method individually. Disparities were especially large for tubal ligation and long-acting reversible contraceptives-methods that other studies suggest are least-likely to be available in Catholic healthcare settings-which may indicate a mismatch between patients' expectations and service availability. IMPLICATIONS: Many reproductive-aged Wisconsin women-especially in rural areas-hold misperceptions about availability of reproductive care in Catholic hospitals. Policies mandating greater transparency in service restrictions and interventions enabling patients to make informed decisions about care may help connect patients to the care they need more quickly.

Closing the contraceptive coverage gap: A multipronged approach to advancing reproductive equity in Illinois.

Despite Illinois' progress in the area of reproductive health, Black, Indigenous, and People of Color, young people, and people with low resources face persistent barriers to high-quality contraceptive care and experience inequities in reproductive health outcomes. Illinois Contraceptive Access Now (ICAN!) is a 5-year initiative that aims to improve the quality and coverage of contraceptive care at community health centers statewide. By leveraging state policies, a robust community health infrastructure, digital innovation, and with a focus on sustainability, ICAN! seeks to cut the "contraceptive coverage gap" in Illinois in half by 2025. As Illinois democratizes access to contraceptive care, this initiative can serve as a model for advancing reproductive equity nationwide.

Prevalence and experiences of Wisconsin women turned away from Catholic settings without receiving reproductive care.

OBJECTIVE: To estimate prevalence of being turned away from a Catholic healthcare setting without receiving desired reproductive care among Wisconsin women and to document firsthand accounts of these experiences. STUDY DESIGN: Between October 2019 and April 2020, we fielded a two-stage survey to Wisconsin women aged 18-45, oversampling rural census tracts and rural counties served by Catholic sole community hospitals. We present prevalence of ever being turned away from a Catholic hospital or clinic without receiving desired contraceptive or fertility care and document accounts of referrals, perceived barriers, and wait times to acquire services elsewhere. RESULTS: The screener response rate was 37.6% (N = 828) and the survey response rate was 83.4% (N = 675). While only 23 (2.0%) of Wisconsin women had ever been turned away from a Catholic hospital or clinic without receiving desired contraceptive or fertility care (95% confidence interval: 1.2%-3.5%), these experiences were more common among women in counties served by Catholic sole community hospitals (n = 9, 8.1% [4.0%-15.6%]) compared to women in other rural census tracts (n = 6, 2.8% [1.3%-6.2%]) and urban census tracts (n = 8, 1.5% [0.7%-3.2%]). Sixteen (69.6%) cited religious restrictions as a barrier to accessing care. Some women - especially those denied tubal ligation - experienced long delays in acquiring time-sensitive care elsewhere. CONCLUSIONS: About 1-in-12 women in Wisconsin rural counties served by Catholic sole community hospitals reported ever being turned away from a Catholic healthcare setting without receiving desired reproductive care. After tubal ligation denials in Catholic facilities, many women faced long wait times to receive care elsewhere. IMPLICATIONS: Wisconsin women in rural counties served by Catholic sole community hospitals were about three times more likely than urban women to have ever been turned away from a Catholic facility. As Catholic healthcare expands nationally, it will be increasingly important to better understand how healthcare prohibitions influence patients' lives.

Mifepristone restrictions and primary care: Breaking the cycle of stigma through a learning collaborative model in the United States.

Despite its safety record, mifepristone is subject to a highly restrictive set of regulatory measures through the Risk Evaluation and Mitigation Strategy (REMS) by the US Food and Drug Administration. We argue that these restrictions both reflect and perpetuate a cycle of abortion stigma, creating particular barriers to mifepristone use in primary care settings where communities that historically experience barriers to care can most easily access reproductive health services. Through qualitative interviews with Illinois primary care clinicians, we discovered how the REMS heightens institutional anxiety over implementation of mifepristone use. To address this, we created ExPAND Mifepristone, a learning collaborative targeting institutional anxiety and logistical barriers to mifepristone use. The learning collaborative model holds high potential to mitigate institutional barriers to mifepristone use by increasing providers' self-efficacy to identify, address, and overcome institutional fears. Until the REMS is fully repealed, learning collaboratives constitute a promising tool to combat the practical and psychological barriers to mifepristone use that these restrictions currently pose.

Expanding access to medication abortion through pharmacy dispensing of mifepristone: Primary care perspectives from Illinois.

OBJECTIVE: Medication abortion is safe and effective, yet access is limited by a strict Risk Evaluation and Mitigation Strategy (REMS) that prohibits pharmacy dispensing of mifepristone. Given the ability of primary care providers (PCPs) to expand medication abortion access, we assessed PCP perspectives on how lifting the mifepristone REMS would affect the provision of medication abortion in primary care. STUDY DESIGN: We conducted a qualitative study of PCPs and administrators in Illinois with experience or interest in providing medication abortion care at their practice. The final sample (N=19) consisted of seven family medicine physicians, three nurse practitioners, four certified nurse midwives, and five administrators. We queried participants on how removing the REMS to allow pharmacy dispensing of mifepristone would affect their ability to provide medication abortion. We conducted interviews via telephone and used ATLAS.ti to manage our transcripts; we analyzed these data for major themes regarding pharmacy dispensing. RESULTS: Primary care providers expressed support for pharmacy dispensing due to its ability to help normalize medication abortion, reduce implementation barriers in primary care, and expand abortion access. Further challenges to address if the REMS restrictions are lifted include federal funding restrictions on abortion, concerns about unsupervised mifepristone use, and pharmacy cooperation. CONCLUSION: Removing the mifepristone REMS to allow pharmacy dispensing could help normalize medication abortion care, facilitate provision in primary care, and address disparities in abortion access. IMPLICATIONS: Our findings illuminate novel benefits of removing the mifepristone REMS and highlight methods to promote successful implementation of pharmacy dispensing. Combined with prior literature, these results support prompt reevaluation and removal of the REMS to align medication abortion care with evidence-based practices.

Denial of tubal ligation in religious hospitals: Consumer attitudes when insurance limits hospital choice.

OBJECTIVES: Postpartum tubal ligation provides demonstrated benefits to women, but access to this procedure is threatened by restrictions at Catholic healthcare institutions. We aimed to understand how insured employees assign responsibility for postpartum sterilization denial and how it impacts their view of the quality of care provided. STUDY DESIGN: We conducted a nationally representative, cross-sectional survey of employees at Standard and Poor's (S&P) 500 companies utilizing a dual panel drawn from Amerispeak, a probability-based research panel, and a non-probability panel. Respondents answered questions about a scenario of a woman denied a tubal ligation due to Catholic hospital policy when her employer-sponsored insurance provided no other hospital choices. Of 1113 eligible panel members, 1001 (90%) completed the survey. Weighted analysis accounted for complex survey design. RESULTS: In response to the tubal ligation denial scenario, 42% of respondents rated hospital quality-of-care as poor or very poor. Sixty percent felt that something should have been done differently, with about half assigning responsibility to the religiously-affiliated hospital for not providing the procedure and half to the insurance company for not including secular hospitals in its network. Finding employers/insurance companies responsible was more common with higher education (RRR = 3.17; 95% CI: 1.58-6.33 some college; RRR = 4.26; 95% CI: 2.10-8.62 bachelor's or more) and less common among non-white respondents (RRR = 0.54; 95% CI: 0.31-0.97). Three quarters of respondents thought the employer should have intervened. CONCLUSIONS: The majority of insured employees do not think women should be denied postpartum tubal ligation. They assign hospitals, insurers, and employers responsibility to remove barriers to care. IMPLICATIONS: Most people who receive health insurance through a large employer disapprove of Catholic hospital restrictions when the patient's insurance restricts her hospital choice. To improve access to comprehensive reproductive care, employers and insurers should assure employees have in-network coverage of hospitals without religious restrictions.

Effects of clinic-level implementation of One Key Question® on reproductive health counseling and patient satisfaction.

OBJECTIVE: We evaluated the effect of clinic level implementation of the One Key Question (OKQ) intervention, including physician and staff training and workflow adjustments, on reproductive counseling and patient satisfaction in primary care and ob/gyn. STUDY DESIGN: We implemented the OKQ intervention in one primary care and one ob/gyn practice, while observing another primary care and ob/gyn practice that each provided usual care (control practices). We surveyed separate patient cohorts at two time points: 26 before and 33 after the primary care practice implemented OKQ, 38 before and 36 after the ob/gyn practice implemented OKQ, 26 and 37 at the primary care control practice, and 31 and 37 at the ob/gyn control practice. We used chi square tests to assess OKQ's effects on counseling rates and patient satisfaction, comparing intervention to control practices across time points. RESULTS: In primary care, from before to after implementation, the intervention practice did not significantly increase reproductive counseling (69-76%, p = 0.58), but increased patient satisfaction (81-97%, p = 0.04) while the control practice demonstrated a decrease in patient satisfaction over the same time periods. In the ob/gyn clinics, no significant change in reproductive counseling or patient satisfaction was seen in the intervention practice, while the control practice demonstrated a decrease in patient satisfaction. CONCLUSIONS: Implementing OKQ appears to increase patient satisfaction. Larger studies are needed to assess whether this clinic-level intervention may increase reproductive counseling. IMPLICATIONS: Further studies of the impact of clinic-level implementation of OKQ are needed.

Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients?

BACKGROUND: Despite millions of U.S. women receiving obstetric/gynecologic or reproductive care in a hospital each year, little is known about which factors matter most to women in choosing a hospital for this care. OBJECTIVE(S): To describe women's reasons for choosing their hospital for obstetric/gynecologic or reproductive care, and to examine characteristics associated with reporting specific factors as important in hospital choice. MATERIALS AND METHODS: We conducted a nationally representative, cross-sectional survey of women aged 18-45 years. The 2016 survey recruited women from AmeriSpeak, a probability-based research panel. A total of 1430 women completed the survey. All data analysis used weighting and accounted for the complex survey design. We conducted bivariate and multinomial logistic regression modeling to assess associations. RESULTS: Three-fourths of women cited a hospital's overall reputation/quality as a reason, and one-third named this as the most important reason for choosing a hospital. A total of 14% reported hospital religious affiliation as a reason. Compared to those with no prior deliveries, women who had delivered an infant were more likely to report that their top reason was specialty services/provider (relative risk ratio, 2.97; 95% confidence interval, 1.96-4.52) and were also more likely to report overall hospital quality/reputation as their top reason (relative risk ratio, 1.52; 95% confidence interval, 1.06-2.17), compared to logistical reasons. Metropolitan versus non-metropolitan residence was also a significant factor in hospital choice. CONCLUSION: Women endorse many factors when choosing a hospital for reproductive care, but perceived quality and reputation outweigh logistical concerns such as location and insurance.

Anticipatory Counseling About Miscarriage Management in Catholic Hospitals: A Qualitative Exploration of Women's Preferences.

CONTEXT: Catholic hospitals represent a large and growing segment of U.S. health care. Because these facilities follow doctrines that restrict reproductive health services, including miscarriage management options when a fetal heartbeat is present, it is critical to understand whether and how women would want to learn about miscarriage treatment restrictions from providers. METHODS: From May 2018 to January 2019, semistructured interviews were conducted with 31 women aged 21-44 who had had exposure to religious-based health care; all were drawn from a nationally representative survey sample. Participants responded to a hypothetical scenario regarding the anticipatory disclosure of miscarriage management policy during routine prenatal care. Responses were inductively coded and thematically analyzed using modified grounded theory to understand women's attitudes and considerations related to receiving anticipatory miscarriage management information. RESULTS: Respondents supported the routine disclosure of miscarriage management policies during prenatal care. Some expressed concern that this might increase patient anxiety during pregnancy, but most felt that the information would serve to prepare and empower patients, and likened the topic to other anticipatory health information provided during prenatal care. Identified themes related to how providers can disclose this information (including the need for a precautionary framing to reduce patient stress), sharing the rationale for institutional policy, and the importance of provider neutrality to ensure patient autonomy. CONCLUSIONS: To respect patient autonomy, health care providers working in Catholic hospitals should routinely discuss institutional miscarriage management policies with patients, and anticipatory counseling should give patients the balanced information they need to decide where to go for care should pregnancy complications arise.

Restrictions on Reproductive Care at Catholic Hospitals: A Qualitative Study of Patient Experiences and Perspectives.

BACKGROUND: Previous studies have shown that many women who would seek care at Catholic hospitals are unaware of the hospital's religious affiliation. Furthermore, women often do not realize that these institutions operate according to religious beliefs that restrict access to certain reproductive services. Our study aimed to gain patient perspectives on experiences seeking reproductive care at religiously affiliated institutions. METHODS: We conducted a qualitative study using in-depth interviews with 33 women who reported experiences seeking reproductive services at Catholic hospitals. Interview questions focused on women's experiences with religious restrictions, their attitudes towards religious healthcare, and whether and how they think women should be informed of these restrictions. Interviews were thematically analyzed using Dedoose software, applying both a priori concepts such as patient autonomy, informed decision making, and transparency, as well as new concepts that emerged from the data or denoted unanticipated distinctions within codes. RESULTS: In this paper, we present three findings. First, women value both patient autonomy and hospital religious freedom. Struggling to reconcile these, many blamed themselves for not anticipating religious restrictions. Second, barriers to information prevent women from researching restrictions ahead of time. Third, women would like more information about these restrictions from both doctors and hospitals. CONCLUSION: Public policy that regulates hospitals should require transparency from hospitals and physicians about religious restrictions on care. Informing the public about religious policies and how they affect reproductive care will allow patients to better anticipate differences and make informed decisions about where to seek care.

"My Hands Are Tied": Abortion Restrictions and Providers' Experiences in Religious and Nonreligious Health Care Systems.

CONTEXT: Abortion is generally prohibited in Catholic hospitals, but less is known about abortion restrictions in other religiously affiliated health care facilities. As religiously affiliated health systems expand in the United States, it is important to understand how religious restrictions affect the practices of providers who treat pregnant patients. METHODS: From September 2016 to May 2018, in-depth interviews were conducted with 31 key informants (clinical providers, ethicists, chaplains and health system administrators) with experience working in secular, Protestant or Catholic health care systems in Illinois. A thematic content approach was used to identify themes related to participants' experiences with abortion policies, the role of ethics committees, the impact on patient care and conflicts with hospital policies. RESULTS: Few limitations on abortion were reported in secular hospitals, while Catholic hospitals prohibited most abortions, and a Protestant-affiliated system banned abortions deemed "elective." Religiously affiliated hospitals allowed abortions in specific cases, if approved through an ethics consultation. Interpretation of system-wide policies varied by hospital, with some indication that institutional discomfort with abortion influenced policy as much as religious teachings did. Providers constrained by religious restrictions referred or transferred patients desiring abortion, including for pregnancy complications, with those in Protestant hospitals having more latitude to directly refer such patients. As a result of religiously influenced policies, patients could encounter delays, financial obstacles, restrictions on treatment and stigmatization. CONCLUSIONS: Patients seeking abortion or presenting with pregnancy complications at Catholic and Protestant hospitals may encounter more delays and fewer treatment options than they would at secular hospitals. More research is needed to better understand the implications for women's access to reproductive health care.

How Should We Judge Whether and When Mission Statements Are Ethically Deployed?

Mission statements communicate health care organizations' fundamental purposes and can help potential patients choose where to seek care and employees where to seek employment. They offer limited benefit, however, when patients do not have meaningful choices about where to seek care, and they can be misused. Ethical implementation of mission statements requires health care organizations to be truthful and transparent about how their mission influences patient care, to create environments that help clinicians execute their professional obligations to patients, and to amplify their obligations to communities.

Perceptions of a Spanish language Reproductive Health Self-assessment Tool Among Spanish-Speaking Women at a Federally Qualified Health Center.

Latinas face barriers to contraceptive and preconception care. Using a Reproductive Health Self-Assessment Tool (RH-SAT) before primary care visits may help overcome these barriers. Twenty Spanish-speaking women at a Federally Qualified Health Center in Chicago received the RH-SAT before their visit then completed a phone interview about their perceptions of the RH-SAT. Transcripts were thematically analyzed using a modified grounded theoretical approach. All participants self-reported Hispanic/Latina ethnicity, either of Mexican (N = 19) or Puerto Rican (N = 1) origin. Participants (1) believed the RH-SAT was easy to use and its content was useful for women with a variety of reproductive goals; (2) felt it provided new information about preparing for pregnancy and contraception; (3) were prompted by the RH-SAT to self-reflect and ask questions not previously considered; and (4) felt it could help overcome barriers some women experience in discussing reproductive health. Participants felt the RH-SAT provided new information and would prompt them to discuss contraception and/or preparing for pregnancy with their clinician. This tool has the potential to facilitate patient-clinician discussion of reproductive health in primary care and overcome barriers experienced by some Spanish-speaking women.