Alex Schulte, Becky Staiger, Amanda L. Brewster, Lori Freedman, Hector P. Rodriguez
Abstract: As demand for postpartum contraception increases, a growing number of hospitals are adopting religious restrictions known as the Ethical and Religious Directives (ERDs) that explicitly prohibit contraception provision. Yet, despite ongoing state and federal policy debates, causal evidence on the longer term health consequences of institutional religious restrictions remains scarce. We use quasi-random variation in geographic proximity to hospitals with and without ERDs to evaluate the effect of giving birth at an ERD-adherent hospital on postpartum contraception and downstream reproductive health outcomes. Our instrumental variable approach uses data on over 9 million birth hospitalizations from 2010–2023 across eleven states. We find giving birth at an ERD-adherent hospital reduces permanent contraception by 3.82 percentage points (pp, 63% relative to the mean) and non-permanent contraception by 1.39 pp (36% relative decrease). Effects are substantially larger for rural patients, for whom ERD-adherent hospitalization reduces permanent and non-permanent contraception by 70% and 71%, respectively. Among rural patients, we subsequently document a 33% increase in short-interval pregnancies, which carry serious maternal and infant health risks. Urban patients show no significant effects on non-permanent contraception or short-interval pregnancy, consistent with greater access to non-hospital contraception options. These findings provide the first causal evidence linking hospital religious restrictions to adverse downstream health outcomes, informing policy debates on hospital transparency, merger oversight, and institutional conscience protections.
Alex Schulte
Abstract: Hybrid organizations—those that embed multiple, often conflicting, institutional logics into a single identity—are increasingly common in healthcare and beyond. Previous research has focused on internal processes and outcomes related to managing these tensions. I provide the first large-scale causal evidence of impacts beyond the organization, finding that the strategies to manage conflicting logics generate negative outcomes for external stakeholders. I develop these arguments in an empirical setting where conflicting logics are particularly salient: U.S. Catholic hospitals, which must simultaneously adhere to Ethical and Religious Directives prohibiting abortion and fulfill professional medical obligations to patient welfare. Using a mixed-methods design that combines a quasi-experimental instrumental variable analysis of over one million hospitalizations with 27 qualitative interviews, I find managing the religious-medical tension results in decreased access to care and worse quality. Specifically, when patients have an urgent, pregnancy-related admission at a hospital with religious restrictions, they are 0.93 percentage points less likely to be induced for an abortion (179% relative to the mean). In addition, vulnerable populations, specifically Hispanic patients and those with complex pregnancies, are more likely to experience abortion-related complications at hospitals with religious restrictions. Crucially, management strategies depend on environmental context: rural hospitals, lacking secular alternatives, cannot outsource the conflict and are more likely to prioritize the medical over religious logic. These findings provide empirical evidence to managers and policymakers building accountability structures, regulatory frameworks, and transparency requirements to limit the negative impacts of organizational tensions on patients and consumers more broadly.
Alex Schulte, Jenny S. Guadamuz
Abstract: Recent federal policy changes, including Medicaid cuts and the Rural Health Transformation Program, have the potential to dramatically reshape maternal health outcomes, especially in rural communities already facing increased barriers to care. To evaluate the impact of these policies and effectively target (increasingly limited) resources, updated data on the chronic disease burden and severe maternal morbidity (SMM) risk of birthing patients is urgently needed. In this study, we fill that gap using an all-payer dataset of 13.5 million deliveries across twelve states from 2010 to 2023. We find that rural residents had a higher prevalence of five of six common chronic conditions, with the largest disparities observed for substance use disorder, depression, and chronic hypertension. In adjusted models, rurality was associated with 21% higher odds of SMM compared with urban residence. SMM rates continue to increase for all populations, despite increased national attention and funding, but notably, have risen more quickly for urban patients since 2018. These findings highlight the need for differentiated strategies—including targeted investments in workforce and infrastructure—to improve maternal health outcomes in an era of constrained federal resources.
A Schulte, B Staiger, HR Rodriguez, AL Brewster. “Mission vs. Margin: The Effects of Catholic Health System Ownership on Hospital Operations.” Medical Care Research and Review. 2025.
SCM Roberts, A Schulte, S Raifman, G Liu, C Zaugg, M Subbaraman. “Mandatory Warning Signs for Alcohol Use During Pregnancy and Birth and Infant Outcomes in Southern U.S. States: a Quasi-Experimental Study.” Alcohol and Alcoholism. 2025.
A Schulte, G Liu, M Subbaraman, WC Kerr, D Leslie, SCM Roberts. “Relationships Between Alcohol Policies and Infant Morbidities and Injuries.” American Journal of Preventive Medicine. 2024.
A Schulte, AH Bennett, J Arcara, et al. “Experiencing a challenge or delay accessing contraception and contraceptive self-efficacy: Data from a 2022 nationally representative online survey.” Reproductive Health. 2025.
A Schulte, A Biggs. “Association between facility and clinician characteristics and family planning services provided during U.S. outpatient care visits.” Women’s Health Issues. 2023.