Ebonie Bailey was seven months pregnant when she and her family moved to Waterloo, Iowa, for her husband’s job at John Deere. Her provider back home had recommended the midwives at Covenant Medical Center, one of two hospitals in town. Ahead of her delivery there, Bailey toured the sprawling brick building. She was surprised when the tour guide pointed out that the hospital had two sides: one Catholic, the other not.   

“I was like, ‘I don’t understand. Do you mean like, there’s a church over there?’” Bailey recalled. “And they were like, ‘Well, there’s certain procedures that cannot be done on that side of the hospital.’”

“I was like, what? What year are we in?” Bailey said. “I was so confused.”

Unbeknownst to many patients who rely on them, Catholic hospitals like Covenant are supposed to follow religious directives that ban abortion, sterilization, and all contraception except for natural family planning. But some of these hospitals have found creative ways to get around the rules.

Bailey’s hospital, which rebranded in February as MercyOne Waterloo Medical Center, had an area that one provider wryly called the “sin room.” Devised in the 1980s following the merger of a Catholic and non-Catholic hospital, the workaround allowed providers to perform tubal ligations and other procedures banned by the Catholic directives in an operating room suite on the labor and delivery floor.

Even outside this area, midwives like Bailey’s freely provided contraceptive prescriptions and Depo Provera injections, as did the OB-GYNs at the hospital, whose independent practice, Partners in OB/GYN, rented office space above the labor and delivery floor. The doctors inserted IUDs in their office; the midwives used the “sin room.”

“We all knew we were violating Catholic hospital guidelines, but we believed we were giving good health care, and so we did what we needed to do to take care of our patients,” Dr. Suzy Lipinski, who worked at Partners and served from 2011 to 2015 as chair of the OB-GYN department at Covenant, said. “We just thought we had a workaround that was acceptable.”

Last year, that all changed. In June, the U.S. Conference of Catholic Bishops approved new directives for Catholic hospitals, declaring that in any affiliation, a Catholic facility must ensure that its administrators and employees will not “manage, carry out, assist in carrying out, make its facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.”

Dubuque Archbishop Michael Jackels cracked down. Representatives from the archdiocese—which includes some 200 parishes encompassing the northeastern corner of Iowa—and from Covenant’s parent company, MercyOne, informed the providers that they would have to stop offering tubal ligations. (Procedures have continued for patients who were already scheduled.) While the hospital never announced it publicly, a new policy implemented on April 1 went even further, banning contraceptive implants like IUDs altogether and allowing other forms of hormonal contraception only for medical reasons like heavy bleeding.

MercyOne declined to answer a detailed list of questions from Rewire.News about the changes and the lack of transparency surrounding them.

“As a Catholic health care organization, MercyOne is called to observe the Ethical and Religious Directives for Catholic Health Care Services (ERDs),” a spokesperson said in a statement. “We work with our providers and colleagues to ensure the medical services we provide are in accordance with these guidelines. We remain committed to caring for the patients and communities we serve in the spirit of our Catholic values and faith-based mission.”

The changes have prompted widespread confusion and outrage, along with a patient exodus. They reflect the longstanding tension between Catholic health system providers and administrators—who may recognize that refusing to offer birth control is not a viable business decision—and the bishops charged with ensuring that hospitals under their jurisdiction comply with Catholic doctrine.

As Catholic systems have expanded their reach, often by merging or partnering with secular systems, the bishops have increasingly tightened the religious rules under which these facilities operate. Reproductive health advocates fear that as a result, interventions like the one in Waterloo could become more common—threatening reproductive health-care access for the one in six women nationwide who name a Catholic hospital as their go-to place for reproductive health care.

“The Highest Level of Malpractice”

On September 7, 2018, the OB-GYNs and midwives at Covenant Medical Center filed into a small classroom for a meeting with the people Dr. Karla Solheim came to think of as the “Catholic enforcers.”

There, representatives from Archbishop Jackels’ office and from MercyOne unveiled a sweeping crackdown on reproductive health care to bring the hospital into compliance with the Catholic directives.

While the directives deem sterilization “intrinsically evil,” Solheim, then chair of the OB-GYN department, protested at the meeting that tubal ligations could be a life-saving procedure for patients, including those who have had repeated cesarean sections and may develop fatal complications if they get pregnant again. The new ban would force patients who had c-sections at Covenant to heal for about six weeks and then undergo a second surgery elsewhere.   

“I am a surgeon,” Solheim told Rewire.News. “We would consider it the highest level of malpractice to force a woman to have two separate surgeries to accomplish something that could be done in one surgery, because we have a high respect for the potential danger and complications of surgery.”

But the officials didn’t seem concerned about that.

Another provider objected to the idea that all patients would master natural family planning, which involves tracking signs of fertility and abstaining from sex during fertile times; as many as 24 percent of women using one of these methods will become pregnant in a year with typical use. This approach also doesn’t work for victims of sex trafficking or abuse, who don’t always get to choose whether to avoid sex, Solheim recalled the provider protesting.

Multiple attendees told Rewire.News they were given numbered handouts of a letter from the archbishop dated September 4, 2018. In the letter, a copy of which was obtained by Rewire.News, Jackels condemned in bold font what he called a “serious moral problem” at the hospital and said that sterilizations “should be completely moved out of and separated from Covenant Medical Center.”

In an ominous sign for hospitals nationwide with similar workarounds, Jackels cited last summer’s revised directives, which decree that the local diocesan bishop must be informed “immediately” if any Catholic hospital is suspected of “wrongly cooperating with immoral procedures.”

According to Jackels’ letter, the workaround had been devised in the 1980s, after Wheaton Franciscan consolidated what was then St. Francis Hospital and Schoitz Medical Center to form Covenant. At first, tubal ligations were allowed at Schoitz, but not at the building a mile away that had been St. Francis. This required some patients to be shuttled back and forth via ambulance if they needed the procedure after giving birth. When the hospital consolidated into one building, administrators devised a plan for tubal ligations: They would build “a condominimized surgical suite that would remain outside the consolidated assets of Covenant Medical Center,” according to a 1988 letter cited by Jackels from Sister Rose Mary Pint, chair of the Wheaton Franciscan board at the time.

In 2016, Mercy Health Network, now MercyOne, took over the Iowa operations of the Wheaton Franciscan Sisters. With hundreds of locations across the state, MercyOne—which is jointly operated by two of the largest Catholic health systems, Catholic Health Initiatives (now CommonSpirit) and Trinity Health—claims to care for more than 30 percent of Iowans. The workaround devised in the ‘80s, Jackels wrote, was never intended to be permanent. He gave the hospital until December 1 to come up with a plan to end it.

At the meeting, some people wrote furious notes on their copies of Jackels’ letter. “This is a bunch of patriarchal bullshit,” one scribbled. At the end of the meeting, officials collected the copies back, apparently taking great care to ensure that none left the room. In red at the top, the papers read: “For meeting purposes only. Please return upon adjournment.”

Dr. MaryBeth Anderson, an OB-GYN who was present at the meeting, said she was surprised by the secrecy.

“I did not like the lack of transparency,” she told Rewire.News. “If that’s who you are, and that’s what you want, you know, own it.”

“How Would I Have Known This?”

MercyOne and Covenant have not publicly announced the new contraception rules, which took effect on April 1. There is no mention of the changes on the hospital’s website.

Ebonie Bailey—who has attended many births at Covenant as a doula and relies on the midwives for her own care—was frustrated that she only caught wind of the changes when someone posted about them on Facebook.

“I didn’t receive anything in the mail, I didn’t get a phone call,” Bailey told Rewire.News. “I didn’t receive any information, so how would I have known this? Would it have been when I called to schedule an appointment?”

This lack of transparency is typical. Less than a third of Catholic hospital websites nationwide mention how the facility’s religious affiliation may affect reproductive health care. Rewire.News found brochures about the directives on Covenant’s website by searching for the phrase “Ethical and Religious Directives”; the information is not readily accessible to patients without a direct search. The brochures mention abortion and sterilization, but not contraception.

To make things more confusing, policies seem to vary widely at MercyOne’s outpatient offices across the state. Rewire.News called about 20 MercyOne practices in late March, just before the new birth control mandate in Waterloo took effect. Some schedulers who answered the phone at family medicine offices said they offered Depo shots and prescriptions for birth control pills, but not IUDs, which are usually inserted by OB-GYNs. At least one MercyOne facility said it did offer IUDs; others said they offered no contraception at all.

This year, Covenant absorbed the remaining providers from the formerly independent Partners in OB/GYN, merging them with Covenant’s group of midwives into one practice with two Waterloo offices. Only one doctor from Partners made the transition. When Rewire.News called these two locations just before April 1, receptionists gave conflicting messages about the new rules: One said the office would no longer provide any contraception and offered a referral to a community clinic. A representative from the other location said they did offer contraception, but, when asked about IUDs, acknowledged they couldn’t insert them in the office.

MercyOne has also not uniformly eliminated tubal ligations at all hospitals, even ones within the same archdiocese as Covenant. Dr. Thad Anderson, an OB-GYN in Dubuque, said providers at the MercyOne hospital there can still do tubal ligations during a c-section, if the patient has had at least one prior c-section. The rules have not changed for years, Anderson said.

MercyOne’s restrictions, while unevenly applied, have major consequences for the state. Tara Shochet, an Iowa-based researcher at the reproductive health group Gynuity, told Rewire.News that she amassed a list of about 300 health centers in Iowa where she thought Medicaid enrollees could go for family planning services. When she learned MercyOne didn’t offer most contraception, she struck 76 centers that appeared to be connected to the health system from the list.

Patients have reacted with fear and anger to the little information that is publicly available. In December, the hospital released a statement saying only that it had stopped scheduling patients for tubal ligations and vasectomies. Within a few weeks, the other hospital in town, UnityPoint Health – Allen Hospital, reported an influx of patients seeking women’s health services.

“We have had at least two, three, or four patients in the last week for sure that have called saying that they came over here from Covenant because of their changes that’s going on with their policies,” nurse practitioner Kathi Bower told the local news station KWWL.

Many of those patients vented their frustration on social media.  

“And just like that, I will change my health care provider and no longer do any business with this organization,” one person wrote in a Facebook comment under a news article about the changes.

“Talk about stupid,” another commenter, Donna DaBillo, agreed. “I guess everyone will transfer to UnityPoint and [Covenant] will lose patients.”

DaBillo’s daughter, Emily, said a nurse at Covenant told her in February that the midwives would no longer be able to provide her Depo Provera shots. To get her next injection in April, Emily would have to go to a pharmacy, pick up the prescription for the shot, and then find another provider to administer it, the nurse said. (Providers have since been told they can give Depo, but only for medical reasons.)

“I have gone to Covenant my entire life and I have gone to the midwives’ office since I became pregnant with my first child over four years ago,” Emily wrote to Rewire.News. “I hate that I now have to go to a new OB-GYN office just to get my birth control, and see a new doctor, rather than the ones I’ve seen for so many years.”

Megan, who asked Rewire.News not to use her last name, was nearing the end of a complicated pregnancy in the fall when her primary care doctor told her that she would not be able to get an IUD through Covenant, or even a prescription for birth control, unless she had a medical condition.

“The c-section I had was one they don’t use much anymore and the cut in my uterus can rupture if I get pregnant again before I’m two years postpartum, but apparently that’s not a good enough reason,” Megan wrote to Rewire.News.

Megan has so far been relying on contraceptive pills prescribed by her high-risk OB-GYN in Iowa City.

“I’m mad that a man could make this decision for all of us regardless of religion,” she wrote. “I’m a Christian but believe contraception can be a good thing. I know we all come from different faiths and lives are being put at risk because the Catholic Church in Dubuque made that decision.”

Another patient, Marie, told Rewire.News that her insurance is only approved at Covenant, not at the other hospital in town, Allen. On top of that, her primary care doctor refuses to provide birth control for religious reasons, she said, although Iowa is not among the states with a specific law safeguarding such refusals.

“I’m in a tough situation along with my sisters that is stopping me from receiving birth control,” Marie wrote to Rewire.News in February. “We are trying to find the proper place that will accept our insurance and provide birth control and it has been a hard road!”

“I’m hoping sooner than later we find someone due to the fact our prescriptions for the pill is running thin and we don’t have many refills left,” she added.

Another patient who asked that her name not be used took issue with the irony of MercyOne’s purported vision: “Radically convenient” health care.

“What is radically convenient—to get your Pap smear here and then go across town to get your birth control?” she asked.

“I Just Didn’t Want to Practice Bad Medicine”

Not everyone has opposed the changes. Dr. Bob Pranger, an independent provider who has admitting privileges at Covenant, said it’s “fantastic” to see the hospital fully embrace the Catholic beliefs that he shares.

“Contraception is an unethical medical practice from the eyes of the Catholic Church, mainly because most of the contraceptive modalities have the capacity to be abortifacient in nature and are disrespectful to life,” Pranger told Rewire.News.

Such claims about contraception are categorically false.  

Pranger and a midwife who works at Covenant, Kristi Allison, are both listed as board members of the local branch of the Guiding Star Project, an organization chaired by anti-choice activist Abby Johnson that is committed to the belief that abortion and contraception “interrupt natural, healthy biological processes.”

“I like that we have an organization in town that’s going to protect life at all stages and I definitely will affiliate myself with [Covenant] in that regard,” Pranger said.

He appears to be in the minority.

Dr. Marcia Rellihan stayed quiet during the September meeting when officials announced the crackdown on reproductive health care at the hospital where she worked for 26 years. By January, she had found a way to make a statement in her own way—by retiring early, at the age of 62.

“I just didn’t want to practice bad medicine,” Rellihan told Rewire.News. “I planned on working a couple more years, but, you know what, it’s just not worth it.”

Because the bulk of her practice involved gynecological surgeries—including tubal ligations—as well as contraceptive prescriptions and insertions, Rellihan said that the restrictions would have cost her an estimated $100,000 in lost salary each year. But it wasn’t the money that made up her mind.

“How can you look at your patients and say, ‘Well, it would be better that you had an IUD for your heavy period, but I can’t do that?’” she said.

She wasn’t the only doctor who couldn’t imagine working that way.  

“I wouldn’t be able to practice gynecology under those circumstances,” Dr. MaryBeth Anderson told Rewire.News.

Administrators have said they won’t audit patient charts to check compliance with the new rules, but Anderson said she would have felt uncomfortable documenting medical reasons for contraception when none existed. Nor was she comfortable denying patients the standard of care.

Dr. Suzy Lipinski left before the crackdown and moved to Colorado, which has a friendlier environment for reproductive rights. As part of a broad assault on reproductive health care, Iowa lawmakers in 2017 forced the state to forfeit federal family planning money in an effort to target Planned Parenthood, which was subsequently forced to close four clinics. Iowa “is becoming a contraceptive desert,” the Des Moines Register warned in an editorial last year.

“I don’t want to be in a state where I have to worry: What new rule are they going to impose that prevents me from taking good care of my patients?” Lipinski said.

Such departures raise concerns in a state that already has the lowest number of OB-GYNs per capita in the country. As more practices find it unaffordable to stay independent, the state’s remaining OB-GYNs may increasingly wind up under the control of Catholic systems—putting reproductive health-care access for even more Iowans in the hands of bishops. Already, at least 42 percent of Iowa’s acute-care hospital beds are in a Catholic facility.

“This affects women’s lives, it affects their health, it affects their finances, it affects their relationships with their partners,” one person affected by the situation in Waterloo, who spoke anonymously, told Rewire.News. “It seems so unfair that this one man has this outsize impact on the health and wellbeing of thousands and thousands of people.”

Tell us your story. Have anti-choice or religious restrictions affected your ability to access health care? Email [email protected].