Catholic healthcare facilities are prolific across the U.S. That’s concerning for some abortion-rights and women’s-health advocates amid the Supreme Court’s decision to overturn Roe v. Wade.

That’s because those seeking access to comprehensive reproductive care may face additional hurdles due to religious restrictions in healthcare centers owned or operated by Catholic entities, according to researchers, advocacy organizations and the association that represents the nation’s OB-GYNS.

The issue isn’t new for Catholic facilities, which do not permit abortions unless to save the life of the mother. With Roe now overturned, women may need to cross state lines for abortions, potentially miscarriage management, and may be unaware how reproductive services are restricted at certain religious facilities under the jurisdiction of the local diocese, stakeholders say.

Some physicians are raising concerns because these entities must abide by the Catholic Church’s doctrine.

"This is something that we are deeply concerned about and have been very concerned about for a long time," Jen Villavicencio, an OB-GYN and leader at the American College of Obstetrics and Gynecology in Washington, D.C., said following the Supreme Court decision.

Catholic healthcare facilities have a large presence in some states where abortion will remain legal and they own more than just hospitals, according to a 2020 report from Community Catalyst, a national health advocacy organization.

In the U.S., one in six hospital beds are in a Catholic facility. However, the church's influence in healthcare reaches beyond acute care hospitals.   

The 10 largest Catholic systems operate about 860 urgent cares, 385 ambulatory surgery centers and about 280 physician groups, according to the report.

At the same time, almost 40% of women of reproductive age live in an area where Catholic hospitals command a high or dominant market share, a 2020 study in JAMA Network Open found. About 35% of all U.S. counties have a high Catholic hospital market share.

Catholic facilities must follow ethical and religious directives that say they can’t provide abortion or sterilization services and may not "promote or condone" contraceptives. The directives, approved by the U.S. Conference of Catholic Bishops, dictate how care is delivered in Catholic institutions, which includes clinics, urgent cares and care delivered by employed physicians.

Religious restrictions are quickly spreading outside of Catholic hospitals as they acquire physician practices and outpatient facilities, said Lois Uttley, a senior adviser at Community Catalyst, who co-authored the 2020 report on the growth of Catholic health systems.

The Catholic Health Association took issue with Uttley’s study and questioned its accuracy when it was released in 2020. At the time, the CHA said one in seven beds are in Catholic hospitals, not the one in six. The organization said at the time it took issue with Community Catalyst’s methodology.

Still, the two largest Catholic health systems alone control a broad array of healthcare services that cut across a major swath of the country.

As of March 31, Ascension says it has 40,000 "aligned" providers across 2,600 total sites of care in 19 states, while CommonSpirit has 25,000 physicians and advanced practiced clinicians in 21 states and 1,500 sites of care.

Neither Ascension nor CommonSpirit responded to requests for comment.

For patients, it’s not always clear how care may be influenced by religious institutions. A 2019 JAMA report found that only 28% of Catholic hospitals disclosed how their religious affiliation may dictate care.

This lack of transparency can result in dire health situations for pregnant people who come to Catholic hospitals with complications. There are reports of women who have shown up with miscarriage complications but were turned away due to the religious directives of Catholic hospitals. If not treated in a timely manner, miscarriage complication can become life threatening to the pregnant person.

Although Catholic institutions can’t provide abortions, there are some exceptions. Still, it’s not always clear when Catholic hospitals can intervene to save the life of the mother, and in those instances, facilities will typically convene the hospital’s ethics committee to determine a course of action.

The U.S. Conference of Catholic Bishops said there is a distinction between what it deems a “direct” abortion and a "legitimate" medical procedure.

In 2010 guidance, the conference explained that a medical procedure that “indirectly” ends a pregnancy is permissible, such as in the case of a pregnant person who is diagnosed with uterine cancer. The removal of the cancerous uterus “directly” addresses the medical problem and “indirectly” ends a pregnancy, according to the U.S. Conference of Catholic Bishops.

However, if a pregnant person is experiencing organ complications due to the "added burden of pregnancy," an abortion isn’t permissible because it’s considered a “direct” abortion.

The bishops released the guidance after a Catholic hospital in Phoenix performed an abortion to save the life of a 27-year-old mother of four in 2009. The Bishop of Phoenix Thomas Olmsted condemned the procedure even though the mother reportedly survived.

A nun, who was also a hospital administrator, allowed the abortion and was ex-communicated from the church for her actions, according to a previous report from NPR. The bishop also stripped the hospital of its Catholic affiliation, ABC News reported.

In some states where abortion remains legal, Catholic healthcare facilities have a large presence and lawmakers should work to make transparency in these institutions a priority, said Marian Jarlenski, a professor at University of Pittsburgh School of Public Health. Jarlenski co-authored a study on Catholic hospital market share.

“I think a very clear policy response would be to say, ‘OK, any healthcare facility that gets any public dollars — Medicare, Medicaid — you should be required to very clearly state which services are and are not available,’”​​​​​​ Jarlenski said.

In 10 states, more than 30% of acute care beds are in Catholic hospitals, which includes Colorado, Oregon and Washington. These are states that have vowed to retain access to abortion.

In Illinois, Catholic facilities represent about 28% of hospitals beds.

“The proliferation of religiously affiliated healthcare absolutely raises concerns about patients access to reproductive health care,” said Ameri Klafeta, director of women's and reproductive rights with the American Civil Liberties Union of Illinois. 

“We also know that there are parts of the state where there may be very limited options for healthcare. So there may be parts of the state where, as a practical matter, the only available healthcare — either by location or by insurance limitations — might be a religiously-affiliated institution,” Klafeta said.

The ACLU of Illinois filed a lawsuit in 2018 after a woman was denied long-acting and reversible birth control at a Catholic facility in Chicago.

The vast majority of abortions in the U.S. are provided in clinics, while just 5% of abortions are performed by hospitals, according to an analysis on abortion incidence in 2017 by the Guttmacher Institute.

Catholic institutions operating more urgent care clinics, physician groups and outpatient facilities raises concerns about complicating access to contraceptives and Plan B, an emergency contraception, commonly referred to as the morning after pill, which is used to prevent pregnancy.

"There may be areas in those states where that care is pretty restricted" as hospitals tend to operate outpatient facilities, urgent cares and manage physician practices in the areas where they own hospitals, said Community Catalyst’s Uttley.