U.S. bishops may soon ramp up efforts to restrict reproductive health care, including women’s access to abortions, at facilities where Catholic hospitals have merged or partnered with their secular counterparts.

The United States Conference of Catholic Bishops (USCCB) this week voted almost unanimously — in a 213-2 vote — to review its policy on “forming new partnerships with health care organizations” to address a directive issued in February from the Vatican’s conservative Congregation for the Doctrine of Faith that, in essence, prohibits Catholic hospitals from merging with secular hospitals that do not uphold the same values.

Today, many of the Catholic hospitals merging with secular counterparts promise that the secular institutions will not be governed by Catholic doctrine — although opponents of the mergers say that reproductive and other facilities thought to counter Catholicism are often slowly phased out.

In Seattle, the Swedish Medical Center was at the center of a controversial partnership with Catholic-run Providence Health & Services in 2011. The Swedish Medical Center promised that it would remain secular, but shortly after the two facilities merged, Swedish announced it would no longer offer elective abortions at its facilities and would instead donate money to a nearby Planned Parenthood facility. Critics say that’s one of many examples of how Catholic hospital mergers affect women’s health care.

But reproductive rights advocates say that foregoing abortions may soon become a pre-requisite for secular hospitals joining with Catholic counterparts.

A copy of Doctrine of Faith’s “guidance” to U.S. bishops obtained by Al Jazeera ruled that, “In a fully collaborative arrangement, the member institutions cannot do together that which each would not do ethically as individual institutions," solidifying the church's stance that even an arguably indirect role in abortion procedures is prohibited.

The Congregation for the Doctrine of the Faith did not respond to an interview request.

Even with the new guidance, it remains unclear what changes in their current mergers policy the U.S. bishops will make. The USCCB said that no one was available to comment on the review.

But advocates in Washington State — a center of the mergers — say the bishops are likely to take a harder stance on health care offered at secular partner facilities.

“What’s interesting about [the review] is that they have not been very clear” about how partnerships and mergers will change, “but we know that the directive to look into this matter came from Doctrine of the Faith. And that is the entity that views as its specific mission enforcing traditional Catholic doctrine,” said Monica Harrington, author of a blog covering the mergers called CatholicWatch.org and co-chair of the advocacy group, Washington Women for Choice.

“We certainly expect that things are going to be made more difficult for patients," Harrington said. "The bishops need to explain what it is they’re doing and how it will affect the existing mergers and takeovers.”

Another Washington reproductive rights advocate, Mary Kay Barbieri, told Al Jazeera she also anticipates Catholic hospitals “are going to say that these mergers can’t be done unless the merging partner agrees to follow” church directives on health care procedures.

In Washington State, the percentage of hospital beds that are in religiously affiliated hospitals has increased from 26 percent in mid-2010 to nearly half, according to the local American Civil Liberties Union. In at least eight states, more than 30 percent of all hospital care is Catholic — and often subject to the directives of regional bishops, according to statistics from CatholicWatch.org.

Harrington said the growth of Catholic hospitals’ presence in Washington State is a consequence of financially struggling hospitals merging with tax-exempt Catholic counterparts.

The potential tightening of regulations comes at a time when Pope Francis is engaged in a bid to ease the Holy See’s stance on issues like homosexuality and divorce.

“To me, what’s fascinating is that there’s so much focus on things the pope is doing that seem to be friendlier and more open, and meanwhile, the bishops here in the U.S. are clamping down on health care systems,” Harrington said.