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: Prior research demonstrates that corporate purpose commitments can be costly to the firm, but largely ignores potential impacts to parties outside the firm. Drawing on corporate strategy and stakeholder theories, I argue that purpose commitments impose substantial costs on dependent non-firm stakeholders—those with urgent and legitimate claims but limited power—and that a firm’s capacity to sustain its purpose depends on the broader market structure. I test these arguments in the setting of U.S. Catholic hospitals, which account for about 15% of the national market share and operate under codified purpose commitments that both promote human dignity and prohibit certain services (such as abortion). Combining a quasi-experimental analysis of over 1 million emergency hospitalizations across ten states (2010-2022) with 27 key informant interviews, I report three key findings. First, compliance with proscriptive purpose commitments significantly reduces access to restricted services and increases complication rates, particularly among less-resourced individuals. Second, purpose commitments are nested; when a proscriptive constraint directly contradicts the organization’s broader aspirational purpose (e.g., patient safety and human dignity), operating units selectively relax the restriction. Third, a firm’s ability to maintain its purpose commitments depends fundamentally on the market structure: urban facilities rely on displacement and outsourcing, whereas rural facilities, which lack transfer partners, are more likely to violate their commitments when clinically necessary. Together, these findings demonstrate that corporate purpose is not an isolated organizational ideal, but a function of market structure that can generate costs past the firm boundary.
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.