Jennie: Welcome to RePROs Fight Back, a podcast on all things repro. I'm your host, Jennie Wetter and each episode I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode I'll be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for RePROs to fight back.

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Jennie: Hi everybody. Welcome to this week's episode of RePROs Fight Back. I'm your host, Jennie Wetter. And before we get started, I have just a little bit of housekeeping. So today we're going to go back to our normal schedule with a new episode every other Tuesday. I hope you all have enjoyed our bonus episodes as much as I have enjoyed doing them. And also I just wanted to let everybody know, I'm always really happy to hear from you. So whether you have a topic that you would like me to talk about on an episode or thoughts about the show, you can always reach out to us. You can do it on Facebook and Twitter at RePROs Fight Back on Instagram at reprosfb or you can email me at Jennie@reprosfightback.com okay, so with that, let's move to today's episode. Today we're going to talk about why it's important to know if the hospital you are going to is a Catholic hospital and how that can impact the care you get once you go to the hospital. So with me today I'm really excited to have Amy Littlefield, an investigative reporter with Rewire.news to talk about the ways that Catholic hospitals restrict reproductive health care. Hi Amy. Thank you so much for being here.

Amy: Hi Jennie. Thanks so much for having me.

Jennie: I'm, I feel like his becoming a thing. No, I'm very excited to talk about some kind of horrible things.

Amy: Me Too.

Jennie: I guess we'll start at the beginning like why are we talking about reproductive healthcare and Catholic hospitals?

Amy: Yes, great question. I think we're talking about it because these hospitals make up a huge swath of our healthcare system. And many patients are aware of this and aren't aware of what that means for their reproductive health care. And the reason why it's important is that Catholic health systems generally follow rules written by the Catholic bishops that ban abortion, which can often be, and they don't provide the standard of care when a patient is miscarrying. Um, they ban most forms of contraception, fertility treatments like in vitro sterilization procedures like tubal ligations and more. And they have also been used to reject gender affirming surgery for trans patients on religious grounds. So when we talk about the scope of the issue, there’s one in six acute care hospital beds, according to the most recent data we have, in a Catholic facility, and depending on the state you live in, that number might be even higher. So there's five states where more than 40% of hospital beds are subject to these Catholic restrictions. Um, Iowa, Wisconsin, South Dakota, Alaska and Washington, and that's according to data from Merger Watch, um, in 2016. So the reason why I think it's important to talk about this is that many people don't realize that this is a thing. Um, when I am a lot of fun at parties, I always want to talk about kind of like hospitals. And by far the most common response I get is, what are you talking about? I had no idea the Catholic church was involved in healthcare. Um, and so oftentimes patients don't realize this until they're denied care. And even when they're denied care, the provider might not necessarily say to them, I'm sending you home with this miscarriage because this Catholic hospital bans abortion care and your fetus has a heartbeat. So I can't help you. You know? So even in these cases, the patient may not realize that they're getting substandard or restricted care simply because the facility is Catholic and follows religious rules.

Jennie: Yeah. I think that's really important because it's one thing to know you're not getting the care that you should be getting, but it's another, if they're just sending you home and not telling you.

Amy: Exactly. And sometimes, you know, when I post my stories on Catholic healthcare online, people who defend these facilities will respond and say, “Well fine, just don't go to a Catholic hospital.” And it's not that simple. I mean number one, because of the information gap we talked about. Right. So, um, and there's been research on this, a study last year actually found that one in six women in the United States name a Catholic hospital is their go to place for reproductive health care. But more than a third of those women were unaware that facility with Catholic. So, and people who were low income, we're less likely to recognize the religious affiliation of the hospital. So it's one of the many ways we know that these restrictions disproportionately impact low income patients and patients of color. And unfortunately it like at time this information gap seems to be by design. So one researcher I talked to Miriam Gueye at the University of Colorado, um, told me she had at one point approached a Catholic institution because she wanted to do some research on what patients expected in terms of whether they could get birth control. And they told her we prefer not to make our patients aware of what we don't offer. Research that she and others have done is shown that of the websites for Catholic hospitals out there, while most mentioned their Catholic identity in some way, only 28% note explicitly how that identity impacts care. So we really can't blame a lot of people for not realizing a that this is out there and be exactly how it can impact their care.

Jennie: Yeah. Yeah.

Amy: I think it's really important that people be aware of it. And the other thing to keep in mind is guess what, even if you know the information and you know your hospitals, Catholic and dozens of communities, at least 46 communities in this country, the Catholic hospital is the sole community hospital meaning generally meaning there's not another hospital for at least 35 miles. So you might not have a choice and if your insurance only covers you there or it's the only place you can reach in an emergency, you don't have the option to go somewhere else.

Jennie: Absolutely. Yeah. No, I was going to say it. In an emergency situation, you don't have any control over that and you don't always know it's a Catholic hospital and you know, so even for people who do know that Catholic hospitals restrict care, which is already a smaller group of the population, you might not know there, your hospital might not be called St Mary's. Right. So you might not know that it's a Catholic hospital.

Amy: Exactly, yeah. Often they have generic sounding names. Um, one of the big systems out in Washington state for example, is called Peace Health, which is a really nice sounding name. It doesn't necessarily have a Catholic ring to it. You know, it can be hard to do that detective work of figuring out how religion might be influencing your health care.

Jennie: Oh yeah. And I just think, you know, as someone who grew up in like a fairly rural area, like when they're, the only hospital you have is the only hospital you've have. And to go somewhere else may mean you have to travel a real long distance and you may already be traveling a distance to get to that hospital.

Amy: Yeah, exactly. And you know, and if it's the one hospital in town, it's pretty likely that it owns all the outpatient clinics in town or that you know, your primary care physician might be affiliated with that Catholic health system or rented office space from that hospital. Um, and so we're seeing at the same time that the Catholic bishops are cracking down on these murders and affiliations. We're seeing that these are not just hospitals, they're health systems that incorporate a lot of different forms of care and where patients might run up against barriers in places they're not expecting.

Jennie: So maybe let's talk a little bit about the types of services that are restricted.

Amy: So last year, the bishops who write the rules for Catholic health systems tightened the restrictions, particularly when it comes to affiliations or collaborations between Catholic and non-catholic entities, saying that in any sort of merger or partnership, the Catholic entity has to ensure “that neither its administrators nor its employees will manage, carry out assisting, carrying out, make its facilities available for make referrals for, or benefit from the revenue generated by immoral procedures.” Which again, when we talk about moral procedures, we're talking about whole range of reproductive healthcare options. And, um, what reproductive health advocates feared would happen is that these changes would be used to crack down on some of the creative workarounds that providers in Catholic institutions have come up with in order to be able to provide things like contraception and tubal ligations to patients despite the Catholic rules. So, and I was able to document an instance where this happened in practice. So I reported on a Catholic hospital in Waterloo, Iowa, that since the 1980s had a workaround that one provider called the sin room where providers could do tubal ligations and insert IUDs and do things that violated the Catholic rules. And in general, the providers at this facility were offering contraception. And this was a deal that was worked out by the nuns who were in charge of the hospital back in the 80s. Um, when there was a merger between a non-catholic and at Catholic hospital in town. And this was sort of the deal. They worked out to be able to preserve services. Well, shortly after the new Catholic directives were released, the local bishop, um, in Iowa came in and cracked down and said, you're going to have to stop providing tubal ligations and vasectomies. And while the hospital never announced it publicly, they actually, um, implemented a new policy that went even further that banned contraceptive implants like IUDs and allowed other forms of contraception only if there was a medical reason, like heavy bleeding. So in Waterloo, which had, you know, two hospitals in town, this was one of them. And where many outpatient places in the region are part of this, um, health system Mercy, one that was implementing these rules, it created a huge scurry among patients to try to figure out how to deal with rules that a) were being unevenly applied and b) were suddenly being implemented in this hospital where many of them had, had been going for many years for care. And so the other hospital in town ended up reporting this almost immediate influx of patients who were trying to get the, um, tubal ligations that they were going to be denied at the other hospital. So I think it's important to look at this example as sort of a perfect storm that we see brewing, which is Catholic hospitals are expanding their reach even while other hospitals are closing or struggling. And especially in rural areas. So the reach of Catholic hospitals has expanded from 2001 to 2016. The number of acute care hospitals that are Catholic grew by 22%. While the overall number of acute care hospitals dropped by 6%. So they're expanding their influence at the same time, they're tightening the rules and getting stricter. And then on top of that, the Trump Pence administration is expanding the ability of these religious providers to discriminate against women and LGBTQ patients and deny care on religious grounds. You know, the Catholic directives generally, um, ban abortion, they ban most forms of contraception except for natural family planning. Um, fertility treatment sterilization procedures are strictly prohibited, although some Catholic hospitals have found work arounds, they'll allow them under certain circumstances. And the ban on sterilizing procedures has been used to deny patients who are transgender and who need, for example, a hysterectomy as part of their journey to bottom surgery. There was a case, for example, um, of a transgender man named Evan Minton who was scheduled for a hysterectomy at a Catholic hospital in California that he needed to get before he could have bottom surgery. And before the surgery, a representative called him just to go over instructions for the surgery. And so he asked for a note to just be made that he used male pronouns. And then the day before the surgery, his doctor called and canceled the procedure because the Catholic hospital had decided the hysterectomy would conflict with its religious rules. Now the doctor told me she performed plenty of hysterectomy versus women in that hospital because the hospital, while it bans tubal ligation procedures and sterilizations, it'll allow it if there's a quote serious and present pathology. And so they might consider, you know, as you know, cancer or something that assists women might have to be a serious and present pathology, but they didn't consider the gender dysphoria that Evan Minton was suffering from to be a compelling reason. So on religious grounds, they deny that procedure. So another sort of example, a lot of times folks don't realize when we talk about bans on abortion that can impact, um, patients who are miscarrying. So, and that can be, you know, a really scary, potentially life threatening process. So I'll give you one example. In 2017 I reported on a case of a doctor in Milwaukee. She had a patient arrive in labor at 18 weeks pregnant, which is long before viability. Um, she had a twin pregnancy. She miscarried one of the fetuses within hours, but the other fetus still had a heartbeat. And so under the Catholic rules, the doctor, um, couldn't end the pregnancy and say the patient's life until she started to show certain signs of infections. So she had to have either a fever of a hundred 104 or higher and uterine tenderness. And at first she didn't have that. So the doctor waited overnight for hours. And then finally the patient's temperature sores to 102 or 103 degrees. So it became a serious situation. The patient was getting really sick, but there were a series of obstacles then because this was a Catholic hospital. So first the doctor couldn't, this is Jessica Ralph is the name of the doctor who told me the story. She couldn't administer Mifepristone, which is an abortion drug. That's part of the standard of care in these cases because the Catholic hospital didn't carry it. And so she thinks that likely prolong the patient's labor. And there was no one at the hospital who was trained to do the simple surgical procedure or dilation and evacuation that would have ended this patient's pregnancy in a matter of minutes. So instead she had to go through labor and it took more than 24 hours. She ended up needing a blood transfusion and having to go through this whole prolonged ordeal to deliver a fetus that had no chance of survival. Um, and you know, this hospital happened to be in a mostly black neighborhood in Milwaukee, a few minutes down the road, there's another hospital, a secular hospital where if this patient had happened to, you know, walk in the door there, she would have been offered a range of options including having a surgical procedure to end the pregnancy again in a matter of minutes, not having to go through labor basically to deliver a fetus that couldn't live. So that's just one example of the many, um, that take place in these facilities because of the Catholic rules.

Jennie: Yeah. It just seems outrageous that women, you have to wait until women's lives are in danger to be able to complete a termination when they're already miscarrying. I mean, as one of many examples.

Amy: Right, exactly. And I think it's one of the ways, you know, it, it sort of shows, um, how these hospitals have tried to adapt what are really religious ideals into practice and deal with the tension between like what patients expect they can get and what, you know, might be a good business decision to be able to offer contraception for example. And what these religious ideals say, which is, you know, no abortions because it, you know, violates these religious doctrines. So it's another complicated layer to that, that these rules are interpreted by individual human beings who may in some cases be even stricter then than hospital policy requires. I mean, I did a story a couple of years ago about a woman, um, in Illinois named Melanie Jones who slipped in her bathroom and dislodged her IUD. And, um, she was bleeding, she was cramping and she went to her doctor just to her outpatient medical provider. And the doctor said that because the outpatient practice was part of the umbrella of the Catholic health system, she couldn't remove Melanie's IUD. And not only that, but she said, nobody in Melanie's health insurance network was going to be able to help her because they all followed the same Catholic restrictions. Um, and she told switching insurance providers could take up to a month. Um, and meanwhile she was bleeding and possibly suffering from internal damage as a result of this IUD. Um, I mean, I'm laughing a little. It's really not funny.

Jennie: It's the laugh or cry.

Amy: Yeah, exactly. Um, and so Mercy said, we were at Mercy Hospital Medical Center, which is a system involved said of course our protocol would, would be to remove the IUD in this example. But again, the issue is these rules are interpreted by individual doctors. They may find a work around and find a way to deliver good care and kind of fly under the radar or they may be afraid of getting fired and follow the rules even more strictly than they need to be followed. Which, you know, seems to be what happened in this case. But again, you have these religious policies that are then being interpreted by the local bishops who are enforcing them and then being interpreted by the, you know, CEOs and leaders that these healthcare systems and then by the individual providers on the ground who are trying to provide reproductive health care within these constraints.

Jennie: Yeah, that story is so outrageous. Um, Eh, you know, you would think even, you know, they're not supporting birth control, but you would think then removing it would be within the bounds of what they would do. Um, hey it, it makes my head hurt. That whole story. Yeah. There are so many stories that I've read through your reporting and through others and it's just, um, again, you think you go to a hospital and you go to a doctor and you get the care you need without putting your life at risk. And I think another place where you see that is with refusing to do tubal ligation during c-sections and making people come back for another procedure.

Amy: Exactly. Which is another thing I think often people don't think about when we talked about the ban on tubal ligation. So often patients who are having a c-section will elect to have a tubal ligation at the same time because it means that instead of having two surgeries, you just have one. And I'm often for patients who have had multiple c-sections, they might feel like there's a health risk if they get pregnant again. Right. And their doctor might advise them it's a good idea to get their tubes tied. But a Catholic hospital won't generally do a tubal ligation. Um, again, some facilities have that of elaborate exceptions. If you can go before the ethics board and meet certain criteria, um, but generally they won't do them. And so what that means is that if you have a c-section in a Catholic hospital, then you have to go home, heal for six weeks or whatever it is from this major surgery that you just had. And then with a newborn at home, um, you know, go and a second surgery and go through another surgery with all the risks of anesthesia and healing and you know, the attendant potential complications that can come with that. So, you know, another example if here of, of where if you don't know in advance at the hospital that you've chosen for delivery or the hospital that happens to be the only place in your town for you to deliver is Catholic. You could end up facing um, restrictions without, um, knowing it.

Jennie: So there is one other thing that, um, when I was going back through your articles really struck me, and I guess it's maybe not necessarily a Catholic hospital thing per se, but it was the pushing, um, burial for miscarriages. And some of the stories I read and you were reporting were just enraging.

Amy: Yeah. So I wrote this article about, um, a Catholic hospital in Indiana where the staff were basically bullying and cajoling patients into, um, burying their miscarried fetuses. And in one case, a patient, I talked to her name, Kate Marshall, had gone through a pregnancy loss. She was really upset, um, and grieving the loss of this pregnancy. And what she wanted to do is send the fetal remains for testing to see if she could determine why the miscarriage had happened and how to prevent one in the future so that she could have a baby. And, um, as she's waiting for surgery, which is a pretty vulnerable and stressful moment already, um, even if you're not going through a miscarriage, the chaplain of the Catholic hospital came in and tried to put pressure on her to bury her fetus, um, as if it were full, you know, a relative or living you and being in this, um, cemetery plot where the Catholic hospital holds these ceremonies periodically. Um, I think for some patients this can be a really healing and welcome thing. But, um, Kate Marshall made it really clear it was not what she wanted at all and she really had to assert herself. Um, with this chaplain, there were multiple visits from these chaplains who kept coming back into her room and trying to pressure her and you know, tell her that she needed to go through with this Christian burial again because of their religious belief. So there were two chaplains involved in this situation and the second chaplain who, um, came into Kate Marshall's room without being invited, Kate Marshall told me she was really aggressive. She refused to leave. And the quote that stuck with Kate Marshall leaders, she accused her of “ sending my baby's remains into a medical slush pile” which again, for somebody grieving off of the miscarriage was a pretty devastating thing. So I think what then happens shortly, a short time later, is that, um, Vice President Mike Pence has been governor of Indiana, signed a law despite protests, um, that would have basically mandated what happened to Marshall. Um, and what happened in this Catholic hospital would have mandated state wide where he mandated the cremation or burial of all fetal remains, um, whether they were aborted or miscarried, um, as part of sort of the agenda of imposing religious beliefs, not just on patients in Catholic hospitals but on everyone and imposing this sort of idea of “fetal personhood” and you know, making that rhetorical argument by imposing this inhumane policy. Um, so it was really traumatizing for Kate Marshall that's sort of after she had been through this terrible experience watch, um, Penn's basically make this a law of the land, um, which made it pretty stressful for her when she was going through her next pregnancy. So I think, you know, there's several ways in which Catholic hospitals sort of offer us a preview of the world that, um, pants and Trump are trying to create. An anti-choice lawmakers are trying to create, you know, world where abortion is banned and the, you know, consequences may be felt by patients who are having a miscarriage, if the fetus still has a heartbeat. Um, where, you know, contraception is increasingly hard to get with the restrictions that we've seen on the title 10 program. Um, and where, you know, every fetus or embryo, no matter how small a get some full, a Christian burial, um, that's the agenda that a lot of these Catholic health systems have been pushing for many years. And it's increasingly the agenda that we're seeing from the federal government.

Jennie: Yeah. And including the attacks on the trans community too as well. Absolutely. So when, when, when the, that we know a little bit about some of the policies we're seeing and the impacts. I think it's also really important to talk about who is the most impacted.

Amy: I mean, when it comes to Catholic hospitals, among the people who are, and really any restriction among the people who are going to be most impacted are those who are economically marginalized. So the people, for example, who take a day off work to go to their birth control appointment, don't realize that, you know, their doctor's office has changed hands and is now part of a Catholic health system, can't get their contraception and then can't afford to take another day off work to get that prescription or that IUD. And multiple studies recently have shown that people of color in particular bear the brunt of these restrictions. So, um, Karen Shepherd, he's a researcher at Columbia. Columbia University has law rights and religion project, um, put out a report called bearing faith and it showed women of color are more likely to give birth in Catholic hospitals where religious beliefs impact their care. She and her colleagues analyzed data from 33 states and Puerto Rico and found that in 19 of those states, women of color were more likely to give birth in a Catholic hospital. And nationally, 53% of births at Catholic hospitals are women of color versus 49% at non Catholic hospitals. So, and in some states it's even more dramatic. So New Jersey women of color represented 80% of births at Catholic hospitals, even though they're only half of women of reproductive age. And so, and again, like the example I gave in the beginning about the patient of the pregnancy in Milwaukee, you know, that hospital happens to be in a mostly black neighborhood and if this patient had been in a different geography, geographical location, it happened to go into the secular facility, um, she would've had a completely different experience. It's also, there was a recent study that came out about Medicaid patients in particular. So increasingly Medicaid programs are outsourcing care to private companies instead of providing it directly. So many of the Medicaid managed care providers are Catholic. And so recent study looked at the Chicago area where 38% of hospitals with labor and delivery units are Catholic and have the seven Medicaid managed care plans in Cook County. Five had a greater concentration of Catholic hospitals in their insurance network than the county as a whole. And 85% of black and Latino women using Medicaid were enrolled in a plan that skewed Catholic versus 75% of their white counterparts. So another example, you know, these Medicaid plans are sort of funneling women of color disproportionately into a Catholic labor and delivery rooms where again, if they show up in an emergency miscarrying or if they want a tubal ligation after their c-section, um, they're going to have potentially trouble getting that care just by virtue of the insurance network that they're a part of.

Jennie: Yeah. I feel like the real tragedy of so many of these reproductive health restrictions and kind of a lot of things in general, is that the most marginalized always seem to feel the most impact, whether that's women of color or, um, people of with low income, they always seem to be the ones who are gonna have the most impact.

Amy: Absolutely. And you mentioned transgender patients too. I mean, and, and that's another area where we see this sort of perfect storm of the Trump Pence administration expanding the ability of religious providers, including Catholic hospitals to deny care on religious grounds. You know, coming out with a rule that basically empowers these discriminatory denials of care opening a special basically pro discrimination office in the civil rights waiting at the Department of Health and Human Services saying to these providers, hey, if you want to deny Karen religious grounds, we're here for you. Um, we're seeing these policies out of the federal government at the same time that on the ground patients are having trouble getting, um, care that recognizes their full humanity providers who are, um, educated and equipped and able because of the religious restrictions, sometimes providers who are willing and to provide the care can't. So we're seeing that like, that sort of conflate that, that, um, intersection of federal policies and then the growing influence of religious providers on the ground kind of intersecting

Jennie: That is one that you're really seeing now is, you know, you, your care is restricted at Catholic hospitals, but if you go to another hospital, your doctors may also have the ability to refuse to treat you because of they have their own personal, um, religious beliefs that the federal government is now protecting in ways that they haven't been before. So what now, um, how can I know if the hospital I'm going to go to is following Catholic directives?

Amy: That is a great question and it's not always too easy to find out. Um, because of what we talked about earlier in terms of some Catholic health systems, not necessarily wanting to be forthcoming with that information because it could be bad for business. So a good first step would be to check the Catholic Health Association directory on the Catholic Health Association website to see if your hospital is listed or if it's part of a wider, a bigger health chain to see if that health chain is listed. Um, another way to do the detective work is to go to the hospital's website and look at the mission statement and the history for any mention of religion. Sometimes they'll have a historical statement about the nuns or you know, the order that founded the hospital logos. That might be a clue and names might be a clue. But again, as you pointed out, not every Catholic hospital is called St Mary's or Saint Joseph. And not every hospital that has a name like Saint Mary's or Saint Joseph is still Catholic or you know has an affiliation because those affiliations can change depending on whether there's a merger or an affiliation with another system. Merger Watch is a great resource. They have reports that list many of the larger systems and then I think the most important way is to just ask your provider do they follow the Catholic ethical and religious directives? Because it may not mention on the website like as these researchers have found, often hospitals don't. So, and I would ask specific questions. You know, if your pregnant ask your midwife or your doctor, if I decided to end this pregnancy, can I get an abortion in this hospital? Well, what would happen if I had a miscarriage and I came into the emergency room? Would you offer me a dilation evacuation procedure? Would you send me away and not get me my full range of options? What is the hospital policy? Ask specific questions about specific services. Is that the best way to figure out what kind of care you're going to get. Because one thing I've found during this work over the past years is plenty of secular hospitals don't offer abortion care or gender affirming care or a full spectrum of reproductive health services. Um, so just because your hospital doesn't have a religious affiliation doesn't necessarily guarantee you that they're going to be offering all the services you might need. So ask specific questions and you know, demand your full range of reproductive health care if you're denied it.

Jennie: Absolutely. And we'll include links to, um, some of the things that Amy mentioned in our show notes. Um, so that people can use them. Um, okay, so Amy, we always like to end with an action. So what can listeners do to ensure that they have access to the care they need and that others do as well?

Amy: Great question. I mean, I think keep an eye on the healthcare landscape in your community. If there's a proposed merger that might involve a health system with religious affiliation, inform yourself about what that could mean. Pay attention and participate in the democratic process. So there've been cases where grassroots groups has gotten together voice concerns about potential Catholic hospital mergers and they've been successful in disrupting them. And the other thing is, like I said, ask specific questions about the care that your providers, um, are able and willing to provide and you know, get the information that you deserve and then spread that information among people in your community. Because the data shows patients overwhelmingly want to know about these restrict religious restrictions. 81% of women say it's important to know about these barriers when they decide where to go for care. Unfortunately, because these facilities are not always so forthcoming, it's up to us to educate ourselves.

Jennie: Absolutely. Um, Amy, thank you so much for doing this. Thank you. It's been a pleasure. For more information, including show notes from this episode and previous episodes, please visit our website at reprosfightback.com you can also find us on Facebook and Twitter at repros fight back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.