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Nearly two in five women of reproductive age may face restricted access to services like abortion, contraception and sterilization, because they happen to live in a county where Catholic hospitals make up a high share of the market, according to a sweeping new report in JAMA Network Open.

In the first-ever study of its kind, researchers analyzed patient discharge data in almost every U.S. county to determine the market share of Catholic hospitals. They discovered that in 35 percent of U.S. counties, Catholic hospitals have a high or dominant market share, meaning they make up more than 20 percent of patient discharges. Combined, these counties serve an estimated 39 percent of U.S. women of reproductive age.

The findings have important implications for access to reproductive health care in these communities. Patients in Catholic hospitals have had their care dangerously delayed while suffering miscarriages, been pressured into burying their miscarried fetuses and had their gender-affirming surgeries canceled on religious grounds. But many patients have no choice but to go to one of these hospitals, the study shows. In 101 counties, Catholic hospitals had a market share of more than 70 percent. In seven U.S. counties, that share was more than 90 percent, data provided by the researchers to Truthout showed.

“If you thought about a particular type of phone having 80 percent of the market, that would be shocking to people, right?” said Marian Jarlenski, an author of the report and assistant professor at University of Pittsburgh Graduate School of Public Health. “We thought it was interesting and significant just how many counties fell into that range of more than 20 percent of the market, of all the hospital discharges, being attributable to Catholic hospitals,” Jarlenski added.

While legal restrictions on reproductive health care have proliferated in Republican-led states in the South, the study underscores how Catholic hospitals tend to dominate areas of the country that are seen as more progressive on reproductive health access, including the Pacific Northwest.

“The Upper Midwest, the Pacific Northwest and to a lesser extent, the Eastern megalopolis from New York to Boston, are some of the areas with more restricted access,” said Coleman Drake, another study author who is also an assistant professor at University of Pittsburgh Graduate School of Public Health. “It’s interesting to see this variation occurring in places that one normally doesn’t associate with restricted access.”

Whether a patient is forced to seek care in a Catholic hospital depends not only on where they live, but on their insurance network. A study last year in Contraception found that in the Chicago area, Medicaid-managed care plans were disproportionately funneling women of color into Catholic facilities.

While the most recent study did not look at Medicaid plans, the researchers did look at plans sold in Obamacare marketplaces. Nationwide, the median marketplace plans in most counties had a lower share of Catholic hospitals than the counties overall. But in 440 counties, patients can inadvertently select a health insurance network that has a Catholic hospital market share of more than 80 percent. That is particularly concerning because of how hard it is to determine ahead of time whether a plan is dominated by Catholic options.

There are no regulations requiring marketplace health insurance plans to disclose how facilities in their networks restrict reproductive health care. Less than a third of Catholic hospital websites nationwide mention how the facility’s religious affiliation impacts care, and more than a third of women who rely on Catholic hospitals for care don’t realize the facility is Catholic, prior research has found.

“I worry about the ability of people to make informed choices here,” Drake told Truthout.

Finally, the researchers examined the demographics of residents in counties where Catholic hospitals are dominant. They found that overall, populations in counties with high or dominant Catholic hospital market shares were more likely to be white, Latino, more educated, and have higher annual median incomes than their counterparts in other counties. They were also slightly more likely to be Catholic. But the differences were small.

A prior study by researchers at Columbia Law School’s Law, Rights, and Religion Project found that women of color were more likely to give birth in Catholic hospitals. That suggests that Black women may be directed to Catholic hospitals based on factors other than where they live.

“If we see that Black women are more likely to deliver in Catholic facilities, it would suggest that their health plans or their obstetric providers are directing them to Catholic institutions,” Jarlenski said.

The researchers said they hoped their study would draw attention to a reproductive health care access issue that has received relatively little scrutiny compared to legal restrictions on abortion.

“The main thing we’re trying to do here is just shed light on this issue and provide some more transparency,” Jarlenski said. “I hope to provide health care systems and policymakers the impetus to think about aligning the services with the needs of the patient.”

Amy Littlefield is a freelance investigative reporter focused on the intersection of religion and health care.

Copyright, Truthout. Reprinted with permission. May not be reprinted without permission.

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