When Angela Valavanis was deciding where she wanted to give birth, she didn’t give the matter much thought. Her obstetrician was affiliated with Presence St. Francis, a well-regarded hospital just north of Chicago, and that was where she had delivered her previous child almost four years earlier. She saw no reason not to return for her second and — she hoped — final delivery. She was planning for a natural delivery, but she wrote in her birth plan that if she had to have an emergency C-section, she wanted the doctors to perform a tubal ligation (commonly called “getting your tubes tied”) during her surgery so she wouldn’t get pregnant again in the future.

It wasn’t a secret that St. Francis was a Catholic hospital. If the name wasn’t enough of a giveaway, the crosses on the walls made the religious connection hard to ignore. But the implications of Angela’s decision to have her baby at this particular hospital didn’t become clear to her until she was being wheeled into the operating room for a C-section after three exhausting days of labor. It was the middle of the night, and she and her husband, Stel Valavanis, were foggy and frightened. But as she was being prepared for surgery, Angela reminded the doctor she wanted a tubal ligation.

There was a pause. And then the doctor said, “We can’t do that.”

Valvanis was taken aback. “It felt like when you’re in the grocery store and the underage kid behind the register says he can’t sell you a bottle of wine,” she recalled later. “So I said, ‘Well who can?’ And they said, ‘No one.’”

Because St. Francis was governed by Catholic doctrine, which opposes almost all forms of birth control, no tubal ligations could be performed on hospital property or by hospital employees, the couple were informed. It was the first they had heard about the restriction. Angela wishes she’d known about the restrictions in advance so she could have gone to a different hospital. St. Francis did not respond to a request for comment.

Over the last two weeks, FiveThirtyEight has covered the growth of Catholic health systems in the U.S. and what that means for patients trying to access some types of reproductive health services that aren’t provided in Catholic institutions. We talked to dozens of people involved in the industry, and there were plenty of topics on which they disagreed. On one issue, though, a number of Catholic ethicists and reproductive rights advocates were united: Patients should be given more information about what it means for a facility to be religious.

Even the savviest patients can have a hard time parsing what health care services are available where because there’s substantial variation in how the church’s ethical guidelines are applied at each hospital. Some Catholic hospitals make accommodations to provide banned services through loopholes that church leaders and ethicists view as moral compromises, while others discourage doctors from even referring patients to facilities that offer banned services.

Nearly everyone FiveThirtyEight spoke with agreed that religious individuals shouldn’t be forced to provide procedures that contravene their beliefs. The Catholic Church sees abortion as a “grave sin” and views efforts to artificially prevent pregnancy as “intrinsically wrong,” which is why Catholic hospitals aren’t allowed to offer abortions and contraceptive services are limited. From the perspective of Catholic theology, these services aren’t health care at all, since they don’t directly address to injury or disease, according to Charlie Camosy, a professor of theology at Fordham University. But many professional medical groups and some Catholic organizations disagree — and with such a high percentage of health care institutions now adhering to these beliefs, the question of how much transparency is owed to patients has become more relevant than ever.

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Written by members of the U.S. Conference of Catholic Bishops, the Ethical and Religious Directives are a set of guidelines that outline how Catholic moral principles should be applied to a range of health care issues — some administrative, some pastoral, some medical. According to this document, the Catholic commitment to the sanctity of human life means that no Catholic institution should perform an abortion, provide certain forms of artificial fertilization, offer sterilizations, prescribe birth control, or remove feeding tubes from patients who are brain-dead.

Those guidelines don’t result in uniform practice, however. Local bishops are responsible for overseeing the hospitals in their diocese. But the bishops can vary in their levels of involvement with hospital protocol, which means that hospital administrators and ethics boards are often functionally responsible for interpreting what the directives mean in everyday practice. Sometimes in the past when nonreligious hospitals were incorporated into Catholic systems, clinicians’ demands for a workaround led to increasingly byzantine solutions that allowed procedures banned by the directives to be performed on hospital grounds by taking advantage of technicalities — for example, floors or rooms were leased to outside medical groups and abortions and sterilizations were performed only in those areas.

These loopholes may explain the results of a recent study of how often certain procedures are performed in hospitals before and after they change ownership, from secular to Catholic or vice versa. Being Catholic reduced facilities’ abortion rates by 30 percent and rates of tubal ligations by 31 percent. Researchers expected to find that these rates were lower in Catholic hospitals, but were surprised that they drop-off wasn’t even more drastic, said Elaine Hill, a professor at the University of Rochester Medical Center and one of the paper’s authors.

Sales or mergers can also lead to changes in the services offered by a previously nonreligious hospital or doctor, sometimes without providing much — or any — warning to patients. After giving birth to her son, Angela Valavanis went back to her doctor’s office to get a prescription for birth control pills, only to discover that the obstetrician had sold her practice to St. Francis and could no longer prescribe contraception in her office. Angela vaguely remembered receiving a letter informing her of the sale, but it contained no information about how the new ownership might affect what services she could receive.

When the first law permitting Catholic hospitals to conscientiously object to providing some kinds of care was passed by the Senate in 1973, there was already concern about how patients would know what a hospital would and wouldn’t do. New York Sen. Jacob Javits added an amendment that would have required hospitals to be transparent about their practices. “Should not [these limitations] be very open and public; so that, for example, a woman is not going to dash into such a hospital without notice that the hospital will not do what she may want done, and therefore she would be able to help herself by seeking assistance elsewhere?” he said at the time. Other senators were skeptical that patients wouldn’t know what Catholic health care means, and the amendment was dropped before the bill passed the House, according to historian Ronit Stahl, a fellow at the University of Pennsylvania. But today, we know that Javits’s concern was founded — many women don’t know how their care might be impacted by the religious affiliation of the facility they go to.

Often it isn’t clear, even to doctors, why a particular service is available at one hospital but not another. Dr. Jessika Ralph, who is now a fellow in family planning at Northwestern University, spent her residency in obstetrics and gynecology at Milwaukee’s Medical College of Wisconsin, which has a partnership with two local Catholic hospitals. In one hospital, Ralph recalled, doctors were allowed to prescribe birth control pills for contraceptive purposes and tubal ligations were sometimes permitted by the ethics board, which offers case-by-case guidance in difficult or unique situations. At the other hospital, neither form of contraception was permitted and doctors frequently referred patients to a third Milwaukee hospital, which wasn’t religiously affiliated, for sterilizations. Ralph said she often worried about whether her patients — some of whom didn’t speak English — could keep it all straight.

Catholic ethicists say that these practices — especially workarounds like third-party leases — aren’t necessarily in line with Catholic hospitals’ mission. Dr. G. Kevin Donovan, a bioethicist at Georgetown University, said that Catholic health care institutions need to be careful to ensure that they’re not perceived as offering or endorsing a prohibited form of care. “It can’t look like Catholic institutions are shutting one eye,” he said. “People who are espousing their principles should be seen as following those principles themselves.”

Thanks to a recent update, the directives may be applied more uniformly in the future. In June, the bishops released the sixth version of the guidelines, which spells out what should happen when a Catholic hospital is sold to, merges with or partners with a non-Catholic hospital. This update was prompted by changes in the broader health system that often encourage or require hospitals to partner with other health providers. Increasingly, hospitals are no longer standalone entities but just one part of large networks involving doctors, insurers, pharmacists and clinics. As hospitals move into areas like preventive health, they’ll need to coordinate more with providers outside of hospitals, said the Rev. Charles Bouchard, the senior director for theology and ethics at the Catholic Hospital Association.

In response to the ongoing frenzy of mergers, the new version of the directives makes clear that maintaining a hospital’s fidelity to the edict is paramount. Catholic hospitals are forbidden from even collaborating with other institutions that won’t comply with certain aspects of the directives. “If there’s a secular hospital that performs abortions or uses reproductive technologies that aren’t allowed, then that’s off the table. The merger can’t happen,” said Jozef Zalot, an ethicist with the National Catholic Bioethics Center.

As the health care industry becomes increasingly consolidated, the question of what services a facility provides is likely to become ever more relevant. Patients with certain types of insurance may find that religious hospitals dominate their network, reducing their access to some types of reproductive health care. In rural communities where a Catholic hospital is the only provider for miles, the tension between patients, clinicians and the hospital may be especially difficult to resolve. When there are few options available, increased transparency may not make much practical difference.

But in areas where patients have more health care options, increased transparency would go a long way, according to Lorie Chaiten, the director of the reproductive rights project at the Illinois chapter of the American Civil Liberties Union. (The ACLU has sued Catholic health care providers in a variety of states, arguing that the church’s restrictions discriminate against women and other groups.) “People need information so they can make a choice about where to seek care,” she said.

Information about the range of services offered by her local Catholic hospital would have helped Angela, who never got her tubal ligation. Instead, she and her husband decided that he would get a vasectomy — a choice that turned into its own medical odyssey, when they discovered that their insurance plan only covered a Catholic health care group affiliated with St. Francis. They waded through layers of bureaucracy before Stel finally obtained a referral to get the vasectomy at a nonreligious hospital.

The experience still upsets her. “No one had ever warned me that there might be these restrictions,” she said. “It’s all so impersonal and opaque when you sign up.” She paused and sighed. “The bottom line for me is that if you’re going to deny care, you need to tell people before they’re in a situation where it’s too late.”

And that’s just the problem, according to many advocates of greater transparency. The exemptions and restrictions aren’t monolithic. And if you don’t know the restrictions exist, how can you ask your doctor — or the institution your doctor works for — whether they abide by them?

CORRECTION (August 2, 2018, 11:40 a.m.):An earlier version of this story misstated the time elapsed between the births of Angela Valavanis’s children. They were almost four years apart, not almost nine.

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