Fifty years ago this week, Pope Paul VI published Humanae Vitae, the papal document that banned all forms of “artificial” birth control, from condoms to prescription methods like the pill as well as sterilization. It’s a dubious anniversary marking half a century of harm to women, especially poor women, and Pope Francis, a champion of the poor, will mark the anniversary year by making its author an official saint.

But Humanae Vitae affects more people than just Catholics: The Catholic bishops who implement Church policies have been very active in trying to overturn birth control coverage in the United States and limit abortion access for immigrants—and President Donald Trump seems more than happy to do their bidding.

Humanae Vitae is what’s known as an encyclical, it’s a letter from the Pope to his bishops that explains a formal teaching. In 1968, it put into official policy the longstanding teaching that modern birth control was "intrinsically wrong" because, among married couples, every sexual act should be open to the possibility of children, says Sara Hutchinson Ratcliffe, vice president of Catholics for Choice. Her group recently released a report titled “Humanae Vitae: the Damage Done.” The only birth control method allowed is natural family planning, in which women monitor their fertility and avoid sex on the days they’re most likely to get pregnant. Not even the pull-out method is acceptable to the Church.

The ban was a shock when it was introduced. Pope Paul VI ignored the advice of his own commission formed to study birth control, which said that it encouraged the Pope to change the teaching on birth control. He banned it anyway, and most Catholics seemed to turn around and ignore the Pope. It was a spectacular flop.

Church attendance fell by a third from 1963 to 1974, and “almost half of the decline in mass attendance can be accounted for by the changing attitude toward birth control,” according to a Church-sponsored study.

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In 1970, just two years after Humanae Vitae, two-thirds of Catholic women were using banned methods of birth control. By 1974, 83 percent of Catholics said they disagreed with Humanae Vitae. And, by 2008, 98 percent of Catholic women who’d had sex said they’d used a birth control method other than natural family planning, according to the National Survey of Family Growth.

“Most people choose not to use [natural family planning] exclusively, because it’s very ineffective,” Ratcliffe says. The failure rates for natural family planning are as high as 25 percent versus 9 percent for “typical” use of the pill, patch, and ring, and 1 percent for the IUD and implant.

As part of their report, Catholics for Choice also commissioned YouGov to survey 1,000 Catholics in the US in February. Sixty-seven percent said they disagreed with the ban on birth control and 84 percent said they think it’s common for Catholics to use birth control.

Despite the fact that Humanae Vitae was massively unpopular, Catholic leadership started pursuing policies that that would effectively codify it in the secular world since it wasn’t enforceable by the Church, Ratcliffe says. That meant supporting policies that limited access to birth control, which disproportionately harms lower-income women and women of color.

“For the 50 years [following its publishing], the bishops, and in the US, the United States Conference of Catholic Bishops, tried to get public policy that mirrored that religious teaching because they did not have the support of, nor the following from, the faithful in the pews,” Ratcliffe says. To do that, the USCCB started to align itself in the late 80s and early 90s with the conservative religious community—specifically, the evangelical community and the Christian Coalition.

Humanae Vitae has been enshrined in the policies of Catholic-owned hospitals across the country thanks to a document that the USCCB maintains and updates, called the “Ethical and Religious Directives for Catholic Health Care Services.” The Directives are essentially a policy manual for implementing Humanae Vitae in healthcare settings; they prohibit contraception, sterilization, and abortion, even when a pregnancy endangers a woman’s life or health.

Thanks to a boom in hospital mergers, one in six hospital beds in the United States is in a facility that follows the Catholic Directives, according to a 2016 report from the American Civil Liberties Union (ACLU) and MergerWatch titled "Health Care Denied." In some states, it’s as high as 40 percent. Overall, 548 hospitals in the US follow the Directives, an increase of 22 percent between 2001 and 2016.

This increase means that more Americans are being denied the family planning services first banned by Humanae Vitae—in the contexts of both routine and emergency medical care. A January 2018 report from Columbia Law School found that women of color are more likely than white women to give birth at Catholic hospitals because of proximity to their community and thereby are subjected to medical care dictated by bishops rather than doctors. Women of color already experience pregnancy complications at higher rates than white women, and they have an even more urgent need to receive care of the highest medical standards.

Catholic hospital systems are also buying up physicians’ practices, and people have gone in for appointments only to be denied birth control or told they can’t get a vasectomy. In order to then find the contraception they were seeking, these patients would have to pay for the original appointment, then find another doctor who accepts their insurance, supports their desire for birth control, and pay for that appointment, too. (This is to say nothing of the 530,000 full-time employees of Catholic hospitals whose insurance is unlikely to cover birth control or vasectomies.)

Brigitte Amiri, deputy director at the ACLU’s Reproductive Freedom Project, knows the harm that the Directives have caused. Women have shown up at emergency rooms in pain from a miscarriage, only to be turned away because the hospital follows the Directives that ban doctors from treating the miscarriage (treatment would be to speed the termination of the pregnancy).

One ACLU client, Tamesha Means, had her water break at 18 weeks and sent home twice by her local hospital, Mercy Health Partners in Muskegon, Michigan. When she showed up a third time, now with an infection, the hospital prepared to discharge her until she started going into labor. Only then did the hospital start treating her. The ACLU sued the USCCB directly, since they enforce the restrictive hospital policies; they were not successful, but the lawsuit has encouraged other women to come forward.

Denial of care for miscarriages violates federal law under the Emergency Medical Treatment and Active Labor Act (EMTALA), which says that hospitals that accept federal funds, and most do, must provide emergency care to patients who come to the ER, Amiri says.

Amiri’s team has also sued Catholic hospitals for refusing to tie women’s tubes during a C-section, when they’re done having children. In the case of Jessica Mann, this refusal put her health at risk: Her doctors said a future pregnancy could kill her. Each of these women would have to undergo a second, unnecessary surgery in order to get their tubes tied. One Chicago area woman couldn’t even get a Catholic hospital to remove her IUD after she fell and the device become partially expelled because the hospital’s religious restrictions barred any treatment involving a non-hormonal IUD, since its sole purpose was to prevent pregnancy. (Hormonal IUDs can be used to treat health conditions like heavy periods and menopause.)

The Church isn’t only trying to exert its influence in Catholic hospitals. It also objects to anyone’s health insurance having to cover birth control and doesn’t agree that it should have to provide reproductive healthcare to immigrants in Catholic-run shelters.

When the Affordable Care Act’s contraceptive coverage benefit was announced in August 2011, the bishops started fighting it even though churches were exempt, Amiri says. In a comment to the proposed mandate to cover prescription birth control, lawyers for the USCCB wrote:

“First, we comment on the mandate that all health plans cover prescription contraceptives, sterilization, and related patient education and counseling. This mandate, we submit, should be rescinded in its entirety. These are not ‘health’ services, and they do not ‘prevent’ illness or disease. Instead, they disrupt the healthy functioning of the reproductive system, introducing health risks in the process; and they are designed to prevent pregnancy, which is not a disease.”

The American College of Obstetricians and Gynecologists begs to differ that contraception isn’t a health service, saying in a 2016 statement: “ACOG recognizes that access to comprehensive reproductive health care services is essential to women’s health and well-being. Women should have access to scientifically based healthcare. Prohibitions on essential care that are based on religious or other non-scientific grounds can jeopardize women’s health and safety.” Birth control is also used for many health reasons besides preventing pregnancy.

They also argued that the ACA required coverage of drugs that can cause abortions, which is false. The ACA required coverage of FDA-approved methods of birth control, including emergency contraception, which prevents pregnancy and does not cause abortions.

The following month, the bishops formed an ad hoc committee on religious liberty, outlining their dissent over the contraceptive coverage mandate, having to provide contraception and abortion to trafficking victims in government-funded shelters, and having to supply condoms and contraception for international health programs. (They also objected to marriage equality, but that’s a whole other story.)

This redefinition of religious liberty is how “they’re going to get politicians who they have some clout with to do their bidding in public policy,” Ratcliffe says. But that’s not how religious freedom is supposed to work. “It’s the freedom to believe and practice your beliefs as you see fit. But it’s also the freedom from anyone else’s one single view of religion being imposed upon you, being codified into public law.”

Amiri says the USCCB has also gotten involved in cases regarding birth control access for unaccompanied immigrant minors in their custody. Catholic charities get government grants to house unaccompanied minors and, in 2015, the USCCB was one of several religious groups to formally oppose Obama-era regulations that would ensure access to emergency contraception and abortion when a minor was raped in US custody. They objected on the grounds that the exceptions for religious and moral objections were inadequate.

The groups wrote that exceptions which included referrals could “impos[e] a duty on the conscientious objector to refer for the very item or procedure to which it has a religious or moral objection.” They were essentially arguing that minors raped in US custody would have to stay pregnant if they happened to be placed at a Catholic-run shelter.

In 2016, the ACLU sued the Obama administration for letting Catholic-run shelters kick out minors who had even requested abortions; the suit was filed under a separation of church and state theory and the case is still ongoing. “We’re trying to stop the government from allowing religious entities to impose their religion on these marginalized populations,” Amiri says.

The 2016 election was a gift to the USCCB. “They’re trying to do an end run around the very people they supposedly represent to our elected officials to get them to enact public policy that follows a teaching that no one in the Church follows,” Ratcliffe says. “And in the current administration, they certainly have found their mouthpiece to be able to do that.”

Trump chose as his running mate the evangelical Christian Mike Pence, a man who doesn’t think condoms work and has a long, anti-choice history as both a representative and as the governor of Indiana. Eighty-one percent of white evangelical Christians voted for the Trump-Pence ticket, but only 52 percent of Catholics.

The Trump administration has appointed many extremely conservative Catholics and Christians in positions relating to reproductive health inside HHS, in the White House, and of course, the Vice President’s office. These appointments “have really been [the bishops’] ticket to make this policy real,” Ratcliffe says.

And indeed, you can see shades of Humanae Vitae and the bishops’ goals.

In May 2017, Trump signed an executive order “promoting free speech and religious liberty” which was intended to authorize “regulatory relief” for religious objections to the Obamacare birth control mandate. Trump also invited to the Rose Garden signing ceremony the Little Sisters of the Poor, a group that runs a chain of 30 Catholic nursing homes and that took a lawsuit over the mandate all the way to the Supreme Court.

The executive order instructed several government agencies to consider amending the regulations. In October, they did just that, posting a final rule that would allow any employer, including large, for-profit companies to stop covering birth control for moral or religious reasons, effective immediately. A spokesperson said the changes “affirm the Trump Administration's commitment to upholding the freedoms afforded all Americans under our Constitution." The USCCB said in a statement that the rule that was “a return to common sense, long-standing federal practice, and peaceful coexistence between church and state.”

The rule has been blocked on procedural grounds (the Little Sisters of the Poor joined the case on the administration’s side) but the ACLU sued for different reasons and its case is still pending.

“It’s a violation of the Establishment Clause, the guarantee of separation of church and state, for the government to authorize employers to invoke their religion to withhold a benefit that is otherwise guaranteed by law from their employees,” Amiri tells me. “We also think that its sex discrimination.”

In January, the administration announced a new “Conscience and Religious Freedom Division” of the Health Department’s Office of Civil Rights, which would offer protections to healthcare providers who don’t want to provide services based on religious or moral beliefs. It means that health workers at facilities that receive federal health funds—including all 5,500 hospitals in the US—could deny people birth control, abortion, and sterilization. Basically, it allows people at secular hospitals and doctor’s offices to act as though they work at a Catholic-run facility and deny care. Unsurprisingly, the USCCB supported the move. “We are grateful that HHS is taking seriously its charge to protect these fundamental civil rights,” it said in a statement.

Then in February, the Trump administration announced that Title X, the nation’s family planning program, would prioritize giving federal grants to groups that focus on natural family planning rather than ones that offer the full range of FDA-approved birth control methods. Based on the grant announcement and proposed changes to the program overall, it’s seems likely that federal grants will for the first time go to religiously affiliated groups that don’t offer any methods of birth control beyond natural family planning. The administration is also being sued over these changes to Title X.

Pope Francis, who assumed the papacy in 2013, has seemed at times more progressive on reproductive issues, including abortion. For instance, he wrote in April that Christians who put opposition to abortion above social causes like fighting poverty are misguided. “Our defense of the innocent unborn needs to be clear, firm and passionate. Equally sacred, however, are the lives of the poor, those already born.”

Ratcliffe acknowledges the shift. “Pope Francis is a breath of fresh air from his predecessors for many of us. His willingness to talk about issues that affect the poor, that we need to take our foot off the gas of the obsession that the hierarchy has had on issues related to abortion and contraception, LGBTQ rights, and others, and really focus on the ways we can help the most vulnerable of our society around the world is something Catholics feel a kinship with and are inspired by.

“That being said, he has indicated that he will not change the policy on Humanae Vitae at any time for any reason,” she says. And, yes, he will canonize its author, Pope Paul VI, in the fall. “For those of us who are both women and Catholic, I think we see him with a little bit less rose-colored glasses because we understand that this policy affects us most egregiously.”

As with most things in the realm of healthcare, changes that limit access affects people already facing barriers to care. “People with means will always be able to get access to contraception and abortion,” Amiri says. “Restrictions on reproductive healthcare will always hit hardest those who are most marginalized—people who live in rural areas, young women, immigrant women, women of color. It’s true that a disproportionate impact will be felt, and has always been felt, on the marginalized among us.”

Ratcliffe says the people most affected are those who have the least means to get care. It’s people “who are covered by programs like Medicaid, those who rely on programs like Title X, those who really don’t have that many options when it comes to healthcare generally, and certainly those who don’t have access directly to reproductive healthcare specifically.”

Making it harder to get birth control will only perpetuate the cycle of poverty. If people can’t effectively control the size of their families, it will be harder for them to complete their education and get a job with an income that can sustain their family and invest in their children’s futures. Access to low- or no-cost birth control is linked time and time again to fewer unintended pregnancies, perhaps because research has shown that when costs are eliminated, women choose more effective methods of birth control like the IUD, which can cost more than $1,000 upfront without insurance.

Many women have abortions for economic reasons (and many abortion patients are have low incomes) and evidence suggests that increased access to birth control reduces unintended pregnancies and thereby abortions. (In 2011, 45 percent of the 6.1 million pregnancies in the US were unintended and 42 percent of those ended in abortion.) In 2015 alone, 6.2 million women in the US received publicly supported birth control services which helped women prevent 1.9 million unintended pregnancies, and averted 876,100 unplanned births and 628,600 abortions.

Rescinding Humanae Vitae—and encouraging the use of contraception as a means for families to control their economic futures—is what one might expect from a Pope who views the lives of the poor as sacred, but Pope Francis has not indicated any inclination in that direction. So the bishops will keep on fighting.

“We’ve all built our lives on being able to make our own decisions about reproductive healthcare and if that is taken away from us, it will...be devastating for so many people across the country,” Amiri says. “We must all be determined not to go back.”

The bishops’ lobbying against birth control—and its ripple effects—is particularly personal for Ratcliffe. “The idea that we as Catholics are being represented by a group of people who are pushing a policy that hurts the most vulnerable of our society first and worst is...beyond an affront to our Catholic values,” she says.

Correction: 7/27/18: The story has been corrected to address several errors. It has been updated to reflect that religious nonprofits are not exempt from the Affordable Care Act's contraception coverage requirement; they have an accommodation so that the insurance company will cover the cost of these medications. Second, the Emergency Medical Treatment and Active Labor Act (EMTALA) only applies in cases of labor and miscarriages that are emergencies; hospitals are not required to perform tubal ligations under EMTALA. Finally, while Mike Pence was raised Catholic, he now considers himself to be an evangelical Christian. We regret the errors.