Objective
The purpose of this study was to assess how common it is for obstetrician-gynecologists who work in religiously affiliated hospitals or practices to experience conflict with those institutions over religiously based policies for patient care and to identify the proportion of obstetrician-gynecologists who report that their hospitals restrict their options for the treatment of ectopic pregnancy.
Study Design
We mailed a survey to a nationally representative sample of 1800 practicing obstetrician-gynecologists.
Results
The response rate was 66%. Among obstetrician-gynecologists who practice in religiously affiliated institutions, 37% have had a conflict with their institution over religiously based policies. These conflicts are most common in Catholic institutions (52%; adjusted odds ratio, 8.7; 95% confidence interval, 1.7–46.2). Few reported that their options for treating ectopic pregnancy are limited by their hospitals (2.5% at non-Catholic institutions vs 5.5% at Catholic institutions; P = .07).
Conclusion
Many obstetrician-gynecologists who practice in religiously affiliated institutions have had conflicts over religiously based policies. The effects of these conflicts on patient care and outcomes are an important area for future research.
Religious denominations sponsor a significant share of health care institutions in the United States. Catholic hospitals account for 16% of admissions to community hospitals, and 4 of the 10 largest health systems are Catholic. Such institutions often have policies regarding patient care that are derived from religious teachings; at times those policies lead to conflicts with physicians regarding how best to care for patients. Popular media have reported recently on cases in which Catholic moral teaching has conflicted with physicians’ judgments about patient care, and a national survey of internists and family physicians found that 1 in 5 of those who had worked in religiously affiliated institutions had experienced conflict with the institution over religiously based policies for patient care. Obstetrician-gynecologists’ experiences of conflict over religious hospital policies have not been examined formally in the literature.
Obstetrician-gynecologists are the physicians perhaps most likely to be impacted by religiously based policies for patient care. Hospitals that are sponsored by a range of religious denominations restrict abortion ; Catholic institutions, in particular, prohibit many common and professionally accepted practices that are related to sexuality and reproduction. For example, the Ethical and Religious Directives for Catholic Health Care Services (hereafter, the Directives), which are authoritative for all Catholic health care institutions in the United States, prohibit abortion, sterilization, contraception, and most uses of assisted reproductive technologies.
One area of ambiguity has been how Catholic teaching applies to the treatment of ectopic pregnancy. The Directives state, “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.” In the past, many Catholic ethicists had interpreted Catholic teaching as banning any direct treatment of ectopic pregnancy unless the fallopian tube had already ruptured. Today Catholic ethicists generally agree that salpingectomy may be used to treat an ectopic pregnancy (without the need to wait for tubal rupture) because, in removing the diseased fallopian tube, the fetus is destroyed indirectly as a secondary effect. However, Catholic ethicists still disagree about the moral permissibility of salpingostomy and methotrexate, which are 2 safe and effective methods that are supported by the American College of Obstetrics and Gynecology. There are Catholic ethicists who endorse their use, but others argue that, when the fetus has heart tones (and therefore under Catholic teaching is treated as a living person), performing a salpingostomy (to remove the embryo while leaving the fallopian tube in place) or giving methotrexate constitutes a direct abortion. In interviews, some physicians working at Catholic hospitals report that their hospitals prohibit them from offering methotrexate for women with ectopic pregnancies. To our knowledge, no previous research has assessed quantitatively the experiences of obstetrician-gynecologists with hospital policies that would restrict options for the treatment of ectopic pregnancy.
This study surveyed a nationally representative sample of practicing obstetrician-gynecologists to characterize those who practice in religiously affiliated institutions and to determine the prevalence and correlates of physician-institution conflicts over religiously based policies for patient care. The study also measured the proportion of obstetrician-gynecologists who say that the policies of their institution limit their options for the treatment of ectopic pregnancy and how that proportion varied by the religious affiliation of the institution.
Materials and Methods
Data
The methods of this study have been reported elsewhere. From October 2008 to January 2009, we mailed a self-administered confidential survey to a stratified random sample of 1800 practicing obstetrician-gynecologists aged ≤65 years. We obtained our sample from the American Medical Association Physician Masterfile, which is a database that is intended to include all practicing physicians in the United States. To increase minority representation (especially minority religious perspectives), we used validated surname lists to create 4 strata. We sampled 180 physicians with typical South Asian surnames, 225 physicians with typical Arabic surnames, 180 physicians with typical Jewish surnames, and 1215 other physicians (from all those whose surnames were not on one of these ethnic lists). Physicians received up to 3 separate mailings of the questionnaire; the first included $20, and the third offered an additional $30 for participating. Physicians also received an advance letter and a postcard reminder after the first questionnaire mailing. The University of Chicago Institutional Review Board approved this survey. The requirement for written consent was waived, which is typical for confidential, self-administered surveys.
Variables
For the present study, we asked respondents, “Is your primary place of practice religiously affiliated?” (yes/no). Those who indicated “yes” were asked, “What is the religious affiliation of that hospital/practice?” (Jewish, Roman Catholic, Christian non-Catholic, other), and “Have you ever had a conflict with that hospital/practice over religiously-based policies for patient care?” (yes/no).
We also presented the following clinical vignette: “A 24-year-old patient has left lower quadrant pain. Vaginal ultrasound scanning reveals a 7-week ectopic pregnancy implanted in the fallopian tube, with fetal heart tones present.” We then asked respondents, “Assuming it was technically feasible and you have the appropriate surgical skills, would you be willing to perform a salpingostomy in this case?” (yes/no) and “…would you be willing to perform a salpingectomy in this case?” (yes/no). In addition, we asked, “Do the policies of your hospital or employer limit the options you have for treating ectopic pregnancy in cases like this one?” (yes/no).
Predictors were physician age, sex, race/ethnicity, region, immigration status (born in the United States or immigrated), religious affiliation, and importance of religion. Participants indicated their religious affiliation as Hindu, Muslim, Catholic (Roman Catholic or Eastern Orthodox), Jewish, evangelical Protestant, nonevangelical Protestant, other, or none. They were also asked, “How important would you say your religion is in your own life?” Response options were not very important in my life, fairly important in my life, very important in my life, and the most important thing in my life.
Statistical analysis
We used χ 2 tests for bivariate analyses and logistic regression for multivariate analyses. We carried out all analyses using the survey design adjusted commands in STATA software (release 11.0; StataSoft Corp, College Station, TX). All analyses were adjusted with the use of probability weights to account for oversampling of physicians by ethnic surname and to account for differential response rates among physicians from each of the 4 different strata. In this way, we were able to generate estimates for the population of obstetrician-gynecologists who currently are practicing in the United States. Missing data were excluded from analyses, and we considered findings significant at a probability value of < .05.
Results
Of 1800 physicians who were sampled, 40 were ineligible for this study because they either had retired or had an invalid address. The overall response rate of the survey was 66% (1154/1760). Among respondents, 19 physicians had missing data on whether they worked in a religiously affiliated institution, and an additional 7 physicians had missing data on whether they had experienced conflict with their institution, which left an analytical sample of 1128 physicians.
Approximately 22% of US obstetrician-gynecologists (n = 241) primarily practice in religiously affiliated institutions. Most of these (59%; n = 143) practice in Catholic institutions; 23% (n = 56) practice in Christian non-Catholic institutions; 8% (n = 19) practice in Jewish institutions; 9% (n = 21) practice in institutions with other religious affiliations, and 1% (n = 2) did not report where they practiced. Those who work in the Northeast are less likely to work in religiously affiliated institutions than those in the South, Midwest, or West ( Table 1 ). Those for whom religion is not personally important are also less likely to work in religiously affiliated institutions than are their colleagues who rate religion as fairly, very, or most important. However, obstetrician-gynecologists who work in religious hospitals are themselves religiously diverse and do not differ from other obstetrician-gynecologists with respect to religious affiliations. Physicians who identify as Roman Catholic are no more likely (when the data are controlled for other characteristics) to work in a Catholic hospital (odds ratio, 1.7, compared with those who report no religious affiliation; 95% confidence interval, 0.7–4.1; data not reported).
| Characteristic | Practice in religiously affiliated institution?, n (%) a | P value b | |
|---|---|---|---|
| Yes (n = 241) | No (n = 887) | ||
| Age, y c | 47.3 ± 9.0 | 47.7 ± 9.2 | .58 |
| Sex | .58 | ||
| Male | 120 (21.0) | 485 (79.0) | |
| Female | 121 (22.5) | 402 (77.5) | |
| Race/ethnicity | .43 | ||
| White, non-Hispanic | 177 (23.4) | 583 (76.6) | |
| Black, non-Hispanic | 11 (17.3) | 54 (82.7) | |
| Hispanic or Latino | 12 (18.2) | 51 (81.8) | |
| Asian | 33 (17.9) | 163 (82.1) | |
| Other | 3 (14.4) | 19 (85.6) | |
| Geographic region | .002 | ||
| Northeast | 37 (12.5) | 246 (87.5) | |
| South | 85 (24.1) | 278 (75.9) | |
| Midwest | 67 (27.1) | 179 (72.9) | |
| West | 52 (22.0) | 182 (78.0) | |
| Immigration history | .25 | ||
| Born in the United States | 179 (22.5) | 622 (77.5) | |
| Immigrated to the United States at any age | 60 (18.8) | 255 (81.2) | |
| Religious affiliation | .32 | ||
| No religion | 21 (17.3) | 96 (82.7) | |
| Hindu | 15 (15.4) | 73 (84.6) | |
| Jewish | 38 (25.5) | 118 (74.5) | |
| Muslim | 9 (14.5) | 44 (85.5) | |
| Catholic | 58 (22.5) | 200 (77.5) | |
| Evangelical Protestant | 22 (24.5) | 68 (75.5) | |
| Nonevangelical Protestant | 61 (21.0) | 233 (79.0) | |
| Other religion | 15 (34.0) | 31 (66.0) | |
| Importance of religion | .02 | ||
| The most important | 35 (23.5) | 120 (76.5) | |
| Very important | 86 (23.4) | 287 (76.6) | |
| Fairly important | 77 (25.9) | 240 (74.1) | |
| Not very important | 40 (14.4) | 227 (85.6) | |
a Counts do not equal 241 or 887 for all variables because of the partial nonresponse; percentages are adjusted for survey design to estimate the portion of all obstetrician-gynecologists who practice in the United States with a given characteristic who practice in a religion- or nonreligion-affiliated institution (for example, 21.0% of all male obstetrician-gynecologists are estimated to practice in religion-affiliated institutions);
Among physicians who work in religiously affiliated institutions, 37% (n = 90) have had a conflict with their institution regarding religiously based policies for patient care. Those who work in Catholic institutions were most likely to report such conflicts (52%). Although age, immigration history, religious affiliation, and religious motivation were all associated in bivariate analyses with having had a conflict ( Table 2 ), only working in a Catholic institution remained significant after adjustment for other variables (odds ratio, 8.7; 95% confidence interval, 1.7–46.2).
| Physician characteristics | n (%) a | Have had conflict over religiously based policies (n = 90) | |
|---|---|---|---|
| P value b | Multivariable odds ratio (95% CI) | ||
| Sex | |||
| Male | 40 (31) | .07 | 1.0 (Reference) |
| Female | 50 (43) | 1.4 (0.7–2.9) | |
| Geographic Region | |||
| Northeast | 11 (30) | .53 | 1.0 (Reference) |
| South | 31 (38) | 1.6 (0.5–5.3) | |
| Midwest | 30 (55) | 1.1 (0.3–3.9) | |
| West | 18 (31) | 0.4 (0.1–1.8) | |
| Immigration history | |||
| Born in the United States | 75 (41) | .003 | 1.0 (Reference) |
| Immigrated to the United States at any age | 15 (18) | 0.4 (0.1–1.5) | |
| Religious affiliation (physician) | |||
| No religion | 8 (44) | .002 | 1.0 (Reference) |
| Hindu | 7 (35) | 1.4 (0.2–12.9) | |
| Jewish | 16 (41) | 1.6 (0.3–8.1) | |
| Muslim | 2 (22) | 0.6 (0.1–3.7) | |
| Catholic | 21 (35) | 0.7 (0.2–2.9) | |
| Evangelical Protestant | 1 (5) | 0.1 (0.0–1.3) | |
| Nonevangelical Protestant | 25 (41) | 0.9 (0.2–3.6) | |
| Other religion | 10 (76) | 4.4 (0.2–22.9) | |
| Importance of religion | |||
| Most important | 8 (20) | .010 | 1.0 (Reference) |
| Very important | 30 (30) | 1.0 (0.3–3.4) | |
| Fairly important | 34 (49) | 1.8 (0.5–6.1) | |
| Not very important | 18 (48) | 1.9 (0.4–8.9) | |
| Hospital religious affiliation | |||
| Other religious facility | 3 (16) | < .001 | 1.0 (Reference) |
| Jewish facility | 1 (9) | 0.6 (0.0–8.4) | |
| Christian, non-Catholic facility | 9 (17) | 1.9 (0.3–11.7) | |
| Catholic facility | 77 (52) | 8.7 (1.7–46.2) c | |
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