In Seattle, Swedish Health Services has offered elective abortions for decades. But the hospital agreed to stop when it joined forces this month with Providence Health & Services, one of the nation’s largest Catholic systems.
In late December, Gov. Steve Beshear of Kentucky turned down a bid by Catholic Health Initiatives, another large system, to merge with a public hospital in Louisville, in part because of concern that some women would have less access to contraceptive services.
And in Rockford, Ill., there is resistance to a plan by OSF HealthCare, run by the Sisters of the Third Order of St. Francis, to buy a hospital because of new restrictions that would require women to go elsewhere if they wanted atubal ligation after a Caesarean section.
About 20 such deals have been announced over the last three years, by one estimate, and experts expect more as stand-alone hospitals and smaller systems with no Catholic ties look to combine with larger and financially stronger institutions, in part because changes under the federal health care law are forcing all hospitals to become much more efficient.
There is already considerable tension between Catholic-run medical institutions and the Obama administration over insurance coverage for contraception for employees. The cultural divide over reproductive health is playing out on the campaign trail as candidates debate hot-button issues like abortion and contraception.
But while the growth of Catholic-run hospital networks is a testament to their long history and operational skill, local and state officials, doctors and advocates in many communities are concerned that some procedures that run counter to Catholic doctrine may no longer be available or will be much more limited. Some doctors fear they may not be able to do what’s best for patients, forced to wait to treat a woman who is miscarrying, for example, or to send arape victim elsewhere for an emergency contraceptive.
The restrictions at any given hospital may not be clear. “Women simply don’t know what they’re getting,” said Jill C. Morrison, senior counsel in health and reproductive rights at the National Women’s Law Center.
The confusion is likely to increase.
“We are starting to see what was rare in the past,” said Lisa Goldstein, who follows nonprofit hospitals for Moody’s Investors Service and predicts more such partnerships. The institutions themselves are grappling with how to remain true to Catholic doctrine and serve a broader community. About one-sixth of all patients were admitted to a Catholic hospital in 2010. In many smaller communities, the only hospital within miles is Catholic.
“That is a constant challenge,” said Sister Carol Keehan, president of the Catholic Health Association of the United States, which represents the nation’s roughly 600 Catholic hospitals. “It’s a challenge we take very seriously.”
Being a Catholic hospital means adhering to the church’s religious directives about care, Sister Carol said, but she says hospitals also see their mission much more broadly, including caring for those who are less fortunate and treating patients with respect.
At the Seton Healthcare Family in Texas, a unit of Ascension Health — the nation’s largest Catholic system and largest nonprofit system — officials say partnerships with struggling community hospitals are integral to their mission. Seton’s first partnership, in 1995, was to operate Brackenridge, a public hospital in Austin, because Seton was “not doing enough to care for the poor and vulnerable in central Texas,” said Charles J. Barnett, an Ascension executive.
In that case, Mr. Barnett says the system never agreed to provide services like elective abortions and sterilizations, and public officials and hospital administrators initially struggled to find a compromise. Although another system eventually offered sterilizations on a separate floor of the hospital, complete with a separate elevator, another hospital now provides those services.
One large system, Catholic Healthcare West in San Francisco, announced in January that it was severing its formal ties to the church to better work with hospitals that did not share its faith. The system, renamed Dignity Health, operates 25 Catholic hospitals, which will remain Catholic, and 15 non-Catholic hospitals. While none of Dignity’s hospitals will provide elective abortions or offer in vitro fertilization, the non-Catholic hospitals will not have to adhere to the church’s religious directives.
Dignity officials declined interview requests.
Even as Catholic Healthcare West, however, the system was not without controversy. One of its Catholic hospitals performed what it considered a life-saving abortion in 2009, but the local bishop in Phoenix disagreed, and the nun who allowed the procedure was excommunicated.
In many communities, like Rockford, the question is an intensely practical one: How will patients, particularly women, use services barred by the church? Because none of the city’s three hospitals perform elective abortions, the debate has largely focused on whether a woman who has a C-section can have her tubes tied afterward.
“It would just be an inconvenience to the patient and the physician, who has to make life-and-death decisions,” said Dr. Ronald Burmeister, a retired obstetrician in Rockford who is concerned about the merger.
The merger itself was prompted by the increasing need for hospitals to combine. Despite the federal government’s concern about possible antitrust implications, many believe the city can support just two hospitals. “Rockford needed a strategic partner,” said Andrew K. Bachrodt, a managing director for Kurt Salmon Associates, which advises nonprofit hospitals. OSF already owns a Rockford hospital, OSF Saint Anthony Medical Center.
OSF says Rockford needs fewer hospitals and wants to expand its network to better serve the area. “It’s all about how to deliver care, coordinated and efficient care,” said Robert C. Sehring, an executive at OSF.
OSF has already developed an arrangement in which affiliated doctors can prescribe birth control pills through a separate practice.
A woman who wanted a tubal ligation immediately after a C-section would be able to go to a competing hospital, if her insurance plan allowed. “It’s not like we’re eliminating female sterilization procedures,” said Kris L. Kieper, the chief executive of the YWCA in Rockford, who serves on an advisory committee for the OSF hospital there.
In Louisville, the debate focused on contraceptive services, like elective sterilizations, that had been provided by the University of Louisville Hospital, one member of a planned three-party merger that would have created a large statewide system. There was considerable uncertainty over whether University Hospital would be required to follow Catholic policies, according to a report by the Kentucky attorney general. Officials initially said the hospital would follow Catholic directives but then focused on certain procedures.
“While this evolving explanation may represent an accurate description of the proposed legal structure of the consolidation, it has cast a cloud of vagueness and skepticism over the issue in the public eye,” the report concluded.
Asking women to go across town to another hospital for services is not a solution, said Dr. Peter Hasselbacher, a retired university official who follows health policy in Kentucky. And while women in Louisville generally have a choice of hospitals, women in rural communities may not, he said, adding that many of Catholic Health Initiative’s Kentucky hospitals are the only hospital available.
Catholic Health says there was never a possibility that University Hospital would be allowed to perform services like elective sterilizations. “Our position around the ethical and religious directives never changed. How we communicated that evolved and changed over time,” said Paul Edgett, a senior vice president at the system.
Mr. Edgett says the system will consider future partnerships with non-Catholic hospitals, including University Hospital, as it seeks to position itself as a stronger system as health care evolves. “We all have to adopt and adapt,” he said. But, he added, “we’re not going to compromise our values in the process.”
European Pro-Choice Network 
