Growth of Catholic hospitals has implications for U.S. reproductive care

The Catholic health-care facilities follow directives from the United States Conference of Catholic Bishops that prohibit treatment it deems “immoral”: sterilization including vasectomies, postpartum tubal ligations and contraception, as well as abortion. Those policies can limit treatment options for obstetric care during miscarriages and ectopic pregnancies, particularly in the presence of a fetal heartbeat.

“The directives are not just a collection of dos and don’ts,” said John F. Brehany, executive vice president of the National Catholic Bioethics Center and a longtime consultant to the conference of bishops. “They are a distillation of the moral teachings of the Catholic church as they apply to modern health care.” As such, he said, any facility that identifies as Catholic must abide by them.

The role of Catholic doctrine in U.S. health care has expanded during a years-long push to acquire smaller institutions—a reflection of consolidation in the hospital industry, as financially challenged community hospitals and independent physicians join bigger systems to gain access to electronic health records and other economies of scale. Acquisition by a Catholic health system has, at times, kept a town’s only hospital from closing.

Four of the nation’s 10 largest health systems are now Catholic, according to a 2020 report by the liberal health advocacy organization Community Catalyst. The 10 largest Catholic health systems control 394 short-term, acute-care hospitals, a 50 percent increase over the past two decades. In Alaska, Iowa, South Dakota, Washington and Wisconsin, 40 percent or more of hospital beds are in Catholic facilities.

“It’s all about market share,” said Lois Uttley, a senior adviser to the hospital equity and accountability project at Community Catalyst. Uttley, who has been tracking hospital mergers and acquisitions since the 1990s, said that with fewer choices, patients today face more difficulty obtaining reproductive services.

In Schenectady, N.Y., Ellis Medicine is in talks with the multistate Catholic giant Trinity Health. Last month, in Quad Cities, Iowa, Genesis Health System signed a letter of intent to enter a partnership with MercyOne, also part of Trinity Health. And this semester, Oberlin College had to find a new provider to prescribe contraceptives after outsourcing student health services to a Catholic system that would not provide them.

In rural northeast Connecticut, residents are protesting the prospect of their 128-year-old hospital becoming part of a Catholic system and the potential impact on reproductive services.

“It would be very troubling to see cutbacks in a state like Connecticut,” said Ian McDonald, a stonemason who opposes the proposed deal between Day Kimball Healthcare in Putnam and Massachusetts-based Covenant Health.

Kyle Kramer, chief executive of Day Kimball Healthcare, said the proposed affiliation with Covenant Health would rescue the financially challenged 104-bed hospital.

“Obviously it has connotations,” Kramer said of the proposed move to faith-based ownership. The Catholic directives would “provide guidance,” he said in an interview, while insisting that “the services that we have provided in the past are the same services that we will continue to provide in the future.”

Kramer did not answer questions in a follow-up email about how contraception and elective sterilizations could continue to be provided under Catholic doctrine if their primary purpose is for birth control. Nor did he specify how emergency obstetric care that could result in terminating a pregnancy might be affected.

Covenant Health spokeswoman Karen Sullivan said in an email that as part of the regulatory process, the Catholic health system is drafting a public response to questions by the state’s Oct. 23 deadline. The system, she said, is committed to “ensuring that the Ethical and Religious Directives are applied thoughtfully and with empathy, compassion and respect for every person we serve.”

Catholic hospitals and providers are accredited and held to the same standards as their secular equivalents, according to the Catholic Health Association of the United States, which lobbies on behalf of Catholic hospitals.

But reproductive rights advocates say there has been a steady erosion of services in both Republican- and Democratic-led states because of the growing dominance of Catholic hospitals.

Many patients are unaware of the restrictions because hospital administrators typically don’t outline the services they do not offer, said Sister Simone Campbell, a lawyer who until recently led the liberal-leaning NETWORK Lobby for Catholic Social Justice.

“Many hospitals have dealt with this by being pretty quiet. Dobbs has made it more of a question,” Campbell said, referring to the case that led to the Supreme Court’s overturning of Roe v. Wade.

Catholic facilities may not “promote or condone” contraception, according to the directives—a stance that is not widely shared by the public. Just 4 percent of U.S. adults think contraception is immoral, according to a 2016 Pew Research Center poll. Among Catholics who attend weekly Mass, only 13 percent say contraception is morally wrong, and 45 percent find it acceptable.

The directives, developed in the late 1940s by the U.S. Conference of Catholic Bishops, were updated in 2018, largely to ensure that Catholic doctrine prevails after mergers and acquisitions, according to Amy Chen, a lawyer with the National Health Law Program. They limit options for referring patients to secular facilities, saying employees must not “manage, carry out, assist in carrying out, make its facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.”

Interpretation of the directives varies among hospital ethics committees. But decisions ultimately rest with the local bishop, who is to be kept informed, the directives say, if “a Catholic health care institution might be wrongly cooperating with immoral procedures.”

“Bishops have a great deal of authority in their dioceses,” Brehany said. “A bishop should ensure that a Catholic organization is abiding by the directives.”

A 2018 survey published in the journal Contraception found that more than one-third of women who go to Catholic hospitals for reproductive care are not aware of the facilities’ religious affiliation. The study, conducted by researchers at the University of Chicago and the University of California at San Francisco, called for increased transparency among hospitals to raise awareness that patients’ options may be limited at institutions with religious ties.

“Even people who had a very wanted pregnancy are at the mercy of policies not driven by their personal values or by the best interests of their health,” said Debra Stulberg, the chair of family medicine at the University of Chicago and one of the researchers in the 2018 survey.

April King, 40, said she wanted to have her tubes tied immediately after giving birth to her second child in December 2020. The Los Angeles talent agent had suffered three miscarriages and knew her family was complete.

Then she learned she could not get a tubal ligation at Providence Saint John’s Health Center in Santa Monica, where she planned to deliver.

“I was just surprised that [the hospital] could decide that for us,” said King, who ultimately elected to go ahead with her delivery at Providence Saint John’s because of the care she had received there in the past.

Doctors, too, face surprises—and can even be reported to hospital ethics committees for following standards of care.

In Washington state, where 41 percent of beds are Catholic-run, legislators passed a law last year to prevent hospitals from interfering with a doctor’s ability to provide medically necessary care to a pregnant patient whose health or life is at risk.

Annie Iriye, a retired OB/GYN who used to work for a Catholic hospital in Olympia, Wash., testified in support of the bill. In a recent interview, Iriye described wanting to administer medication to hasten a woman’s delivery to stave off infection after her water broke at 18 weeks, before fetal viability. Even though the woman was in active labor, Iriye said other staffers refused to follow her direction as the attending physician because a heartbeat had been detected.

By the time the woman delivered, she had a fever and needed antibiotics. Staffers reported Iriye to the hospital ethics committee.

“I was flabbergasted,” Iriye said. “It’s like, ‘Oh, come on guys. Can’t we just practice medicine and give good care?’ ”

Patients say there appears to be little consistency in how hospital staffers interpret religious directives, with doctors sometimes having to make decisions on the fly.

Whitney Marshall, 29, learned only after waking up from exploratory surgery for endometriosis in 2019 at Ascension Crittenton in Rochester Hills, Mich., that her IUD had not been replaced. Marshall, who uses the device to reduce the pain associated with the condition, had to undergo a second procedure in her gynecologist’s office to have the IUD reinserted. The spokesman for Ascension Crittenton did not respond to requests for comment about the case.

“Some women cannot afford surgeries” to treat endometriosis, Marshall said. “So their only form of recourse is to try to regulate their hormones by using contraceptives.”

Catholic hospitals’ tradition of serving women and children in the neediest neighborhoods is “rooted in our reverence for life,” said Brian Reardon, spokesman for the Catholic Health Association. But the lack of choice has been felt keenly in rural and low-income communities where patients cannot easily transfer to secular institutions, reproductive rights advocates say.

Hospitals operating under Catholic restrictions are “the sole community providers of short-term acute hospital care” in more than 52 communities across the country—up from 30 in 2013, according to Community Catalyst.

In Putnam, Conn., residents have relied on Day Kimball Healthcare, the town’s only hospital, for more than a century.

Kramer, the chief executive, said the hospital has been exploring partnerships with larger systems over the past decade to ensure its long-term survival.

The proposed arrangement with Covenant Health requires the approval of Connecticut’s Office of Health Strategy, which has been examining how services might be affected.

The need to preserve access to reproductive health services can bring an end to negotiations. In 2012, the investor in a proposed joint venture with two hospitals in Waterbury, Conn., one of which was Catholic, pulled out after reproductive health advocates and the local archbishop raised opposing concerns about creating a “hospital within a hospital” to provide reproductive services—a workaround that had been successful elsewhere.

Access to reproductive services has shrunk recently around Day Kimball after the 2020 closure of Planned Parenthood in nearby Danielson.

Like many hospitals, Day Kimball does not provide elective abortions, according to documents filed with the state. But it has provided other care prohibited by Catholic directives, including elective sterilizations.

Those services are key to preventing unwanted pregnancies, said Lee Wesler, an internist who has been affiliated with Day Kimball for a decade.

“Any unwanted pregnancy is a potential abortion,” Wesler said.

Members of the group Save Day Kimball Healthcare said that in conversations, Kramer and other representatives of the hospital have sought to be reassuring. “They say, ‘Everything will be fine,’ ” said Margaret Martin, a retired social worker and member of the group.

Kramer, who said he intends to stay on if the Covenant deal goes through, repeated those assurances to The Washington Post. “What we have been we will still be,” he said, while declining to describe how contraceptives could be offered for the sole purpose of birth control.

In a Q&A posted in September on the Day Kimball website, Kramer suggests that other justifications could be found for using “tools” such as oral contraceptives, including “to maintain health and wellness, to address a medical condition, prevent disease, and mitigate cancer risk.”

Bruce Shay, a member of the Save Day Kimball Healthcare steering committee, says he worries doctors may leave if they have to abide by the directives – or might evade them by making “a sketchy diagnosis.”

Nandini Seshadri has seen that happen.

The 40-year-old Latham, N.Y. resident received a copper IUD after delivering her first child at a secular hospital that Trinity is in the process of acquiring. She was denied the device after giving birth to her second child at a Catholic hospital now affiliated with Trinity.

“I remember laughing and saying, ‘What? Seriously?’ ” Seshadri recalled. “I didn’t know that Catholic hospitals still did that.”

She was even more surprised when her nurse-midwife offered her a hormonal IUD instead, on the grounds that she needed it to stabilize her menstrual cycle.

“I didn’t have that problem,” Seshadri said. To give her the contraception, she said, the nurse “was essentially falsifying my medical record.”