A northern California Catholic hospital is fighting a lawsuit seeking to force it to perform a tubal ligation, arguing that its ethics code generally prohibits it from performing sterilizations. Some reproductive health experts say that code has created another problem at Catholic hospitals that use it: Limited treatment options for women experiencing pregnancy-related complications.
The organization that lobbies on behalf of the state's Catholic hospitals acknowledges that they follow different protocols in cases of pregnancy complications, including sometimes transferring patients to non-Catholic hospitals. But the group insists that these women ultimately receive the treatment they need.
In the northern California case, the American Civil Liberties Union has sued Mercy Medical Center in Redding on behalf of Rebecca Chamorro, a woman planning to give birth at the facility. Chamorro decided with her doctor that she would have a tubal ligation following her planned Cesarean section in late January. Experts say this sterilization method is common, routine and effective.
The hospital refused, saying its religiously-based ethics code forbids sterilization of men or women unless it's deemed medically necessary.
Mercy Medical abides by the Ethical and Religious Directives for Catholic Health Care Services, written by the U.S. Conference of Catholic Bishops.
Besides prohibiting sterilization in most cases, the directives forbid the promotion of contraceptives. They also prohibit abortion, which ends up limiting how doctors can treat women experiencing pregnancy-related complications.
Critics charge that many women are unaware of the restrictions regarding complications. They argue that the rules could conflict with established standards of care and endanger women's health.
"Limited by church doctrine"
As an example, they point to the situation in which a woman's water breaks early in her pregnancy, well before the fetus is viable. Even if the fetus' heart is still beating, doctors at most non-Catholic hospitals will consider this to be an inevitable miscarriage. They will generally offer treatment to complete the miscarriage because the fetus' prognosis is considered so poor.
Dr. Debra Stulberg, an assistant professor of family medicine at the University of Chicago, says in this scenario a woman's doctor will typically offer three treatment options: Induce labor with a drug to help the uterus expel the fetus; perform a surgical procedure to evacuate the uterus; or monitor the patient to ensure she doesn’t develop an infection.
But church-affiliated hospitals following the Bishops' ethical directives may not induce abortion of a live fetus, so doctors have essentially one option: Monitor the woman and wait for her to go into labor on her own.
The problem with this approach is that a woman can develop an infection during this waiting period, says Dr. Pratima Gupta, reproductive health advocacy fellow for Physicians for Reproductive Health, which is a co-plaintiff in the Redding lawsuit.
"A woman's health and safety are being put secondary in a scenario where we have the knowledge, the ability, we have evidence that there are alternatives that the woman should be offered," Gupta says.
According to the Bishops' directives, doctors have to demonstrate that a woman's health or life is at risk to get a hospital ethics committee to approve treatment with drugs or surgery, Stulberg says. This means that at some Catholic hospitals, doctors can't treat the miscarriage unless the woman develops signs of infection, like a fever or an elevated heartbeat, or suffers excessive blood loss.
"I find these restrictions placed by religious authorities on the care that women can receive extremely concerning," Stulberg says.
Lori Dangberg, Vice President of the Alliance of Catholic Health Care, the lobbying group, counters that doctors at Catholic hospitals carefully monitor women who are miscarrying, and will induce labor if a patient develops signs of infection. This "watchful waiting" method "is not counter-indicated," she adds.
"In those cases, with the administration of prophylactic antibiotics and very close monitoring, any small rise in white blood count or temperature that could indicate an impending infection would be treated as life-threatening and labor would be induced," Dangberg says.
If women don't want to risk infection while waiting for the miscarriage to occur naturally, and choose instead to accelerate the end of a pregnancy, Dangberg says there's one more option: "We would facilitate transfer to a hospital that would accommodate her wishes."
Some in the field criticize this approach. Dr. Mitchell Creinin, a professor and director of family planning in UC Davis' Department of Obstetrics and Gynecology, says he used to work at a university-affiliated hospital on the east coast, a mile away from a Catholic hospital. Once or twice a month, he says, doctors at the Catholic hospital would call his facility, looking for assistance treating a pregnant woman who was bleeding, often heavily, and in the process of miscarrying.
He recalls that they would say, "We know what she needs, but we can’t treat her. We’re going to send her one mile down the road to you so you can help her."
All 35 Catholic hospitals in California – including 13 in Southern California – abide by the directives, according to Dangberg.
Additionally, there are 13 non-Catholic hospitals within the Catholic-associated Dignity Health system that don't follow the directives, she says, adding these hospitals follow their own "Statement of Common Values" rather than the Bishops' directives. This document does not prohibit direct sterilization and other contraceptive acts, but it does bar assisted suicide and embryo destruction. It also prohibits abortion, which Dangberg says would mean they would also follow the same protocols with regard to pregnancy-related complications.
The directives also dictate how doctors treat ectopic pregnancies. In these cases, the fertilized egg implants in the fallopian tube or another area of the woman's body, like the horn of the uterus or the cervix.
At non-Catholic hospitals, doctors typically perform surgery or inject a drug called methotrexate to stop cell growth and dissolve existing cells. Some Catholic hospitals, though, won't offer those options if the fetus shows cardiac activity.
California hospitals that use the Bishops' directives do treat ectopic pregnancies with methotrexate "when indicated ... and a simpler treatment is not available," says the Alliance of Catholic Health Care's Dangberg, "because ectopic pregnancies are a serious and present pathological condition of the mother, which we know can be life-threatening."
Doctors at these hospitals also have the option of transferring women with ectopic pregnancies to other facilities, "but it's unfortunate that the hospital or the physician can't provide appropriate care for reasons that are not related to medicine," says UC Davis' Creinin.
The Alliance of Catholic Health Care insists that there is nothing wrong with the care provided by hospitals that follow the Bishops' directives.
"Catholic hospitals operate in one of the most highly regulated sectors, where California and federal regulators oversee nearly every aspect of what hospitals do," says Dangberg.
"Neither the state nor federal government has identified one instance in which a pregnant woman received inappropriate treatment at a California Catholic hospital, or provided treatment outside the standard of care," she adds.
The California Hospital Association backs Dangberg up. The association, "is not aware of any situation where a faith-based hospital has not provided care consistent with accepted standards of medical practice," says spokeswoman Jan Emerson-Shea.
Nationwide, the number of Catholic hospitals is increasing: Between 2001 and 2011, the number of church-sponsored or affiliated acute-care hospitals increased by 16 percent, while all other types of non-profit hospitals and publicly owned hospitals declined in numbers, according to a 2013 report from the ACLU and MergerWatch, which advocates for reproductive health services when secular and religious hospitals merge.
These hospitals provide an important service, especially in areas where there's limited access to health care, says Creinin.
But "it's important to understand that a Catholic hospital is also limited in some of the reproductive health services they can provide as compared to other hospitals," he adds. "What would be considered medically acceptable and medically appropriate is limited by church doctrine."
"Understand the limitations"
If you or a loved one is planning to have a baby at a Catholic hospital, the doctors I spoke with recommend being as well informed as possible about how Church doctrine could affect the care you might need.
"For women that are getting reproductive health care in these situations, it doesn't mean it's bad health care for most of what you would need, but you just need to understand the limitations of what you can access," Creinin says.
He continues: "Unfortunately, there's no requirement anywhere that a provider or a hospital has to hang out a shingle and say, 'we don't provide these services.'"
So how do you determine exactly which services a hospital will or won't provide, especially if you're experiencing pregnancy complications?
Stulberg recommends asking as many questions as possible. Still, she acknowledges that when it comes to how doctors treat pregnancy complications, "you don't have any way of knowing what are the appropriate questions to ask."
The questions to ask, she says, are:
What does it mean that you work at a Catholic hospital?
What does it mean for me during this pregnancy?
What does it mean for me, as a woman of reproductive age, that this is a Catholic hospital?
"If you aren't satisfied with the answers, keep asking," she says. "And if you're still not satisfied with the answers, I think, if you can, you should look elsewhere."
Have you received reproductive health care at a Catholic hospital? Are you a health care professional working at one of these hospitals? You can share your experiences below or e-mail us at Impatient@scpr.org.
This story was updated on Jan. 13, 2016 to correct the number of Catholic and Catholic-associated hospitals in the state.