The woman inside the ambulance was miscarrying. That was clear from the foul-smelling fluid leaving her body. As the vehicle wailed toward the hospital, a doctor waiting for her arrival phoned a specialist, who was unequivocal: the baby would die. The woman might follow. Induce labor immediately.

But staff at the Mercy Health Partners hospital in Muskegon, Michigan would not induce labor for another 10 hours. Instead, they followed a set of directives written by the United States Conference of Catholic Bishops that forbid terminating a pregnancy unless the mother is in grave condition. Doctors decided they would delay until the woman showed signs of sepsis – a life-threatening response to an advanced infection – or the fetal heart stopped on its own.

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In the end, it was sepsis. When the woman delivered, at 1.41am, doctors had been watching her temperature climb for more than eight hours. Her infant lived for 65 minutes.

This story is just one example of how a single Catholic hospital risked the health of five different women in a span of 17 months, according to a new report leaked to the Guardian.

The report, by a former Muskegon County health official, Faith Groesbeck, accuses Mercy Health Partners of forcing five women between August 2009 and December 2010 to undergo dangerous miscarriages by giving them no other option.

All five women, the report says, had symptoms indicating that it would be safest for them to deliver immediately. But instead of informing the women of their options, the report says, or offering to transfer them to a different hospital, doctors – apparently out of deference to the Mercy Health Partners’ strict ban on abortion – unilaterally decided to subject the women to prolonged miscarriages.

As a result, the report claims, several of the women suffered infection or emotional trauma, or had to undergo unnecessary surgery. None of the women were pregnant beyond 24 weeks, when an infant can survive outside the womb.

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The report has not previously been made public. And it offers a disturbing look at how religious restrictions may interfere with emergency care. Catholic control of US hospitals has ballooned in the last 15 years, and with it, patient advocates warn, the risk that the US Bishops’ bans on abortion, contraception and sterilization will prevent thousands of women from receiving critical healthcare. A 2013 tally found that 381 out of 3,786 the country’s hospitals were Catholic, meaning they followed the Bishops’ rules for healthcare.

Healthcare watchdogs have documented isolated instances in which Catholic hospitals denied women birth control or sterilization procedures. But this report details some of the the most systematic collisions of religion and medicine ever to surface in public.

One of the women described in the complaint was given Tylenol for a potentially deadly infection and sent home – twice – where she miscarried by herself on the toilet. Another woman, the report says, spent three days in the hospital and eventually required additional surgery.

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The report squarely links these events to Mercy Health Partners’ Catholic sponsorship. In the US, hospitals that advertise themselves as Catholic must follow a set of medical directives written by the United States Conference of Catholic Bishops. All doctors working at the hospital must follow church teachings, regardless of their personal beliefs, and the hospital is responsible for instructing its staff on the directives.

Performing, or even facilitating an abortion is prohibited. “Abortion is never permitted,” the directives read. “Catholic healthcare institutions are not to provide abortion services, even based upon the principle of material cooperation.”

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However, the directives make an exception for procedures that are necessary to protect a woman’s health even if the secondary consequence is the death of the fetus. “If the directives are properly applied, there should be no compromise of the wellbeing of human beings,” said Marie Hilliard, the director of public policy for the National Catholic Bioethics Center.

What is not clear in these five cases is how Mercy Health Partners interpreted this exception. Locating the line between abortion and moral action, says Michael Moreland, a bioethicist at Villanova University, is incredibly complex: “When a baby is in medical distress, and the mother is in medical distress, and the directives point to an imperative to protect both human lives, those are the really difficult cases that hospital ethics committees grapple with.”

According to the report, a hospital executive told county health officials that at Mercy Health Partners, “as long as there is a heartbeat, induction of labor is not an option in a Catholic institution unless the mother’s life is in jeopardy”. But the executive, Joseph O’Meara, admitted that the hospital did not have a clear standard for determining when a woman’s life was in jeopardy, the report says.

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The report’s description of the five incidents pulls directly from the women’s medical records. Its author, Groesbeck, was employed at the time by a Muskegon County initiative to reduce infant and fetal mortality, a job that granted her access to medical data that is usually confidential. Recently, Groesbeck provided the report to the Guardian.

On 7 August, 2013, Groesbeck reported Mercy Health Partners to a division of Health and Human Services. Her complaint accused Mercy Health Partners of violating the Emergency Medical Treatment and Active Labor Act, a 1986 act of Congress requiring hospitals to provide any patient experiencing an emergency with “stabilizing treatment”.

Before going to federal authorities, she wrote in her report, Groesbeck took her concerns directly to Mercy Health Partners. “The upshot of the meeting was that MHP stands behind its policies,” Groesbeck wrote.

A potential for ‘fatal consequences’

At its heart, the report accuses Mercy Health Partners of making unilateral healthcare choices for the five women without their knowledge or their consent.

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The women were all experiencing a rare pregnancy complication in which the membranes surrounding the fetus rupture too early. When that happens before the fetus is viable, the rupture leads to a miscarriage.

For the mother, these circumstances are not necessarily dangerous. According to the guidelines of the American College of Obstetricians and Gynecologists (ACOG), it is safe for many women experiencing membrane rupture to go home and monitor their condition until they go into labor.

The danger arises when there are signs of an infection. In that case, said an OB-GYN who reviewed the report on behalf of the American Congress of Obstetricians and Gynecologists, most doctors would “absolutely urge” the woman to allow doctors to induce delivery. The goal is to minimize the risk of the woman developing a severe infection by removing the source. (The OB-GYN spoke on condition of anonymity because she did not personally examine the patients.)

None of the women in the report were more than 20 weeks pregnant – which is several weeks before the fetus can survive outside the womb. And all five women showed signs of infection, the report says, such as an elevated temperature or heart rate.

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Yet staff never informed any of the women that there was an alternative to natural miscarriage – immediate delivery – or that immediate delivery is a safer option for women showing signs of infection, the report says. One woman told Groesbeck that even when she asked medical staff to deliver her infant, they refused.

“In each incident, [Mercy Health Partners] withheld medically indicated treatment and information from pregnant women experiencing emergency situations,” the report reads. “These practices not only risk life-threatening infection, infertility, and health problems, they subject women to unnecessary physical and psychological suffering.”

One woman arrived at the hospital after seeing a fetal limb in her toilet. Staff dilated her, causing “a bulging bag of waters”, but refused her request to break her water and begin delivery, the report says.

“The patient was forced to wait over eighteen hours, while dilated, to complete the miscarriage naturally, resulting in retention of the placenta (a leading cause of maternal hemorrhaging and death) and additional, and potentially unnecessary, surgical intervention to remove it,” the report says. Later, a test of the placenta was positive for infection.

Another woman arrived in the early stages of miscarriage with an elevated temperature and heart rate, the report says. After a natural miscarriage, that woman also required surgery to remove the placenta – which also tested positive for acute infection.

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Yet another patient who arrived with signs of infection was sent home twice without appropriate intervention, the report claims. That woman, Tamesha Means, is suing the US Conference of Catholic Bishops in federal court for enforcing a policy that caused her to receive below-standard care.

The ACOG doctor called the hospital’s actions as described in the report a “pattern of substandard care”.

“It’s not too strong to say that any one of these women could have suffered fatal consequences,” she said.

Mercy Health Partners and its parent company, Trinity Health, declined to respond to detailed questions about the report and the hospital’s policies for this article. But notes from a March 2013 meeting between, Groesbeck, her health department supervisor, and O’Meara, the hospital executive, offer some clues about the hospital’s reaction to the report.

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According to the notes, which the supervisor, Gwen Williams, took by hand, O’Meara claimed that it’s the hospital’s policy to tell women when one of their medical options is a procedure Mercy Health Partners does not provide.

But even the hospital seemed uncertain about what its doctors had told these five women. At the meeting, O’Meara showed Groesbeck and Williams an internal review of the treatment of all five women.

“In cases where I have been involved, the amount of compassion and information given to the mother has been phenomenal,” read the review, according to Williams’ notes. Her notes say the review was conducted by Dr Doublestein, a physician at the hospital. “If that did not happen, then we need to improve our care.”

Doublestein questioned Groesbeck’s conclusion that all the women were showing signs of infection. He concluded that the hospital had acted appropriately in every case, except when doctors reportedly allowed a woman to develop signs of sepsis. In that case, Doublestein said, doctors should have given the woman the option of being transferred to a secular hospital, 45 minutes away, where doctors could induce labor. But even in that instance, Doublestein defended the hospital, saying it wasn’t obvious to doctors that the woman had developed sepsis.

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“There is no ideal way of handling these situations,” Doublestein concluded.

The Guardian submitted questions for Doublestein to the media teams at Mercy Health Partners and Trinity Health, and sent emails to a Dr Gary Doublestein, an OB-GYN working at Mercy Health Partners. The questions received no response. Citing patient privacy, Trinity Health declined to comment on Doublestein’s report.

A nationwide trend

Across the country, a string of Catholic takeovers of secular hospitals has ensured that more and more doctors are following the US Bishops’ healthcare directives.

According to a December 2013 report by MergerWatch, a healthcare watchdog, and the American Civil Liberties Union, the number of Catholic hospitals increased 16% between 2010 and 2011. At the same time, the numbers of public, secular and other religious hospitals all dropped. One out of every nine hospital beds in the US are located in facilities that follow Catholic teachings, the report found, and in 30 communities, the only local hospital is a Catholic one.

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“I can tell you that the trend we cited in [that] report is continuing,” said Lois Uttley, one of the authors. MergerWatch is updating those figures for a report to be released early this year. “Catholic hospitals have banded together to create even larger regional and national health systems, and these giant, Catholic-run healthcare systems are continuing to acquire non-Catholic hospitals.”

Mercy Health Partners in Muskegon County embodies many of these trends. According to Groesbeck’s report, it is the only provider of emergency care in all of Muskegon County – the result of a 2008 merger that gave Trinity Health control of the area’s secular hospitals. Trinity Health ranks among the largest healthcare systems in the country. The non-profit operates 91 hospitals and had 2015 revenues of $11.78bn. Today, the nearest hospital to Muskegon without any religious affiliation is 20 miles away.

The Bishops’ directives, which all Catholic hospitals follow, prohibit a range of reproductive health treatments, such as tubal ligations, or “tube tying”, and abortions for reasons of fetal anomaly.

But experts in Catholic healthcare say the directives as they are written should never interfere with a doctor’s ability to provide the best emergency care. In emergency situations involving a patient who is pregnant, said Dr Kevin Donovan, the director of Georgetown University’s center for clinical bioethics, “There’s no preference for the baby that should put the mother at risk.” The rules also require patients to be fully informed.

The Guardian provided Groesbeck’s complaint to the United States Conference of Catholic Bishops and asked if Mercy Health Partners’ actions, as described in the complaint, were in keeping with the group’s directives. In response, the USCCB media department declined to comment.

Several Catholic organizations, however, have weighed in on similar situations. The Bishops’ rule say that procedures that result in fetal death are permissible if the purpose is to treat “a proportionately serious pathological condition of a pregnant woman”.

The Catholic Health Association has said it qualifies as “proportionately serious” if a pregnant woman is suffering from a rupture and infection of membranes – the condition that allegedly afflicted the five Mercy Health Partners patients. Other bioethicists have said that the woman doesn’t even need to suffer from infection – it’s enough if she’s at risk.

The fact that sources differ, says Moreland, the Villanova bioethicist, is a reflection of how complicated these questions can be for Catholic hospitals.

But researchers and public health advocates say that’s precisely the problem – the Bishops’ rules are open to dangerous interpretation.

They have found many scattered examples. Several years ago, Lori Freedman, a professor of obstetrics, gynecology and reproductive sciences at the University of California-San Francisco, was conducting a survey of abortion services when she realized that six out of the 30 OB-GYNs she interviewed had all raised similar concerns. The six doctors all worked in a Catholic healthcare setting.

“They reported that Catholic doctrine, as interpreted by their hospital administrations, interfered with their medical judgment … [They] are restricted in managing miscarriages,” she wrote . “Although Catholic doctrine officially deems abortion permissible to preserve the life of the woman, Catholic-owned hospital ethics committees differ in their interpretation of how much health risk constitutes a threat to a woman’s life.”

The most infamous example of how doctrine and medicine may clash is the case of Savita Halappanavar . In 2012, Halappanavar’s death in an Irish hospital became an international symbol for the perils of allowing religion to dictate medical care.

Halappanavar was 17 weeks pregnant when she began to miscarry. Later investigations suggest that it should have been clear to doctors that she had an infection. The hospital, allegedly because of its abortion ban, refused to intervene, and Halappanavar quickly succumbed to septicemia.

“Savita is the prototype for why we say this is an unacceptable practice,” the ACOG doctor told the Guardian.

In the US, advocates point to Tamesha Means. Means arrived at Mercy Health Partners on 1 December 2010 after her water broke and she began having contractions. At the time, she was 18 weeks pregnant. Staff sent her home. She returned the next day in “severe pain”, claims the lawsuit she filed, at which time her doctor suspected a “significant infection”. Staff sent her home again. She returned to the hospital and miscarried later that night.

“At no time did [Mercy Health Partners] inform Ms Means that there was virtually no chance her fetus would survive, or that there was a high risk to her health if she continued the pregnancy,” her lawsuit claims. “Nor did the hospital ever tell her that completing the miscarriage by terminating the pregnancy was the safest course and the standard of care.” The lawsuit points to Groesbeck’s report as evidence of a pattern.

A federal judge threw out Means’ lawsuit in July. She and her ACLU attorneys are appealing before the sixth circuit. In his opinion, Judge Robert Holmes Bell said he lacked jurisdiction over the national organization, and that it would be impermissible for him to interfere in the US Bishops’ religious decisions. The USCCB declined an interview request.

“This case has no merit,” said a spokeswoman for Trinity Health, Mercy Health Partners’ parent company. “The Ethical and Religious Directives are entirely consistent with high-quality healthcare.”

‘She felt that they had saved her life’

In the five cases that Groesbeck documented, none of the infants survived. Two of the women delivered stillborns, and three delivered infants that lived between one and 90 minutes. None of the women appeared to suffer long-term physical consequences.

In an interview with the Guardian, Groesbeck stressed that not all of the women viewed their experience with anger. She interviewed three of the patients whose cases appear in her report. “One woman, she felt that they had saved her life,” Groesbeck said. “She was very grateful for the help she had received – even though the hospital withholding the care was what had created the crisis.”

The other women, Groesbeck said, were “pissed”. She shared partial transcripts of her interviews on the condition that the woman not be quoted directly, since they spoke in confidence. One of them described her anger at being given false hope that her infant would survive and at the hospital’s decision to risk her life for a pregnancy that staff knew was no longer viable. The other said she feared for women who didn’t have the money to travel out of the county to hospitals that prioritized the mother’s health when a pregnancy is lost.

Groesbeck became aware of potential problems at Mercy Health Partners through her job with the county. In 2013, when she made her report, Muskegon County was one of about a dozen counties in Michigan that funded a position to reduce fetal and infant mortality. Groesbeck’s job was to interview mothers who had lost very young children and pore over county data to identify gaps in care.

The report she eventually filed, she says, was the product of years of consultation with medical literature experts in obstetrics and gynecology.

Several months after the meeting with O’Meara, the hospital executive, Groesbeck sent her complaint to the Centers for Medicare & Medicaid Services. Investigators opened an inquiry based on her report.

But in the end, they took little action. Investigators cited Mercy Health Partners for a minor infraction – failing to establish in its bylaws who counts as a qualified medical personnel – and closed the matter in March 2014.

Malpractice attorneys who reviewed the complaint for the Guardian said Groesbeck chose the wrong forum: her report mostly documented how Mercy Health Partners had violated standards of medical care. The centers are focused on ensuring that all patients receive the same care, regardless of their ability to pay.

Dusty Fillmore, a Fort Worth attorney who has brought many malpractice cases under EMTALA, says Groesbeck’s report does raise two potential violations. The extent to which investigators examined those two women’s medical records is not clear from the results of the inquiry, which the centers provided the Guardian.

By the time investigators closed their case, Groesbeck was long gone from county government. Twenty-six days after she formally made her report, Muskegon County had to submit an annual outline for her program. The outline, seen by the Guardian, eliminated Groesbeck’s position.

Groesbeck says the county reassigned her to a substance abuse prevention program, so she quit. “It wasn’t the job I had trained for,” she said.

A spokeswoman for Muskegon County blamed budget cuts. State and national coordinators for the fetal and infant mortality program could not speak directly to what happened, but they acknowledged that budget cuts frequently put their work on hold. “Our teams come and go pretty easily,” said Cassandra McNulty, the Michigan coordinator.

Groesbeck has come to believe the move was political. But she has no regrets.

“I talked to anyone who would listen to me,” Groesbeck said. “I felt a moral obligation to do something once the hospital said they weren’t going to do anything about it … There was no way I could not act on what I’d found.”

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