There’s a single hospital in Bellingham, a picturesque coastal city 20 miles from the Canadian border in Washington. So when a Bellingham mental health counselor named Alison started bleeding three months into her pregnancy in 2013, PeaceHealth St. Joseph Medical Center was her only option.

Alison had first gone to her OB-GYN’s private practice, where her doctor, C. Shayne Mora, diagnosed her with a possible case of placenta previa, a serious condition where the placenta blocks the cervix. He told her to go to the hospital if she started bleeding again. When that happened the next day, Alison went to the St. Joseph emergency room. After an ultrasound showed the fetus was viable, the hospital discharged her. Providers recorded a clinical impression of “threatened abortion,” meaning Alison was at risk of miscarrying. They told her to return if she bled more heavily or ran a fever.

Alison, who asked us to withhold her last name for professional reasons, had never thought much about the fact that St. Joseph is part of PeaceHealth, a Catholic system that runs ten hospitals across Washington, Oregon, and Alaska. Catholic facilities, which make up a growing swath of the health-care landscape, follow rules written by the U.S. Conference of Catholic Bishops that ban sterilization, abortion, most contraception, and in vitro fertilization. Washington is one of five states where more than 40 percent of acute-care hospital beds are Catholic. That leaves many patients like Alison with one option: a hospital where care may be restricted by religion without their knowledge.

The next day, Alison started soaking through a menstrual pad an hour and returned to the ER. Her medical records show she was again discharged with plans to see Dr. Mora in his office. Three days later, she woke up in the middle of the night bleeding. Around noon, she passed a blood clot the size of a jawbreaker. In the ER for a third time, she described her pain as a seven out of ten. She was running a fever of 100.4 with an elevated white blood cell count, a classic sign of infection. “Appears anxious,” staff noted in her medical records. But the hospital discharged Alison again, this time telling her that her pain might be the result of appendicitis.

Alison and her husband, Richard Bennett, clung to that idea, because it meant the pregnancy might be safe. At no point, they said, did anyone at the hospital mention that Alison had the option of ending her pregnancy with surgery to address the brewing infection that would end up putting her life at risk. Alison’s records at the time of her third discharge still show a working diagnosis of threatened abortion.

By the next morning, Alison was in significant pain and her fever wasn’t responding to medication. She and Bennett returned to the ER. There, records show, a doctor ordered an abdominal MRI to rule out appendicitis and a chest X-ray to rule out pneumonia.

Then Mora arrived. He did a vaginal exam, and Alison arched off the bed in agony.

“It felt like something from the Exorcist, just like flailing from the pain,” she said. Bennett remembers Alison screaming when the doctor pressed on her abdomen. Alison, who recalls having refused pain medication out of fear it might harm the pregnancy, told Rewire.News that the agony radiating from her infected uterus was worse than non-medicated childbirth. Medical records show her fever had spiked to 101.1. One of Alison’s mothers, Lin Skavdahl, clung to Alison’s hand. Overcome, watching her daughter writhe, Skavdahl stepped away and fainted, sliding toward the floor and putting her hands over her head.

Mora moved quickly. He explained to Alison that she had an infection and needed surgery to end the pregnancy. Bennett asked whether there was any way to save the baby. Mora was firm: No. In fact, Alison’s life might be in danger.

Records show Alison had sepsis, a potentially deadly condition caused by the body’s response to infection. But Mora explained that he couldn’t proceed until the hospital’s ethics committee approved the surgery. Citing Catholic policy, PeaceHealth bans abortion unless its “direct purpose” is the “cure of a proportionately serious pathological condition of a pregnant woman” and it “cannot be safely postponed until the unborn child is viable.” In other words, the hospital would permit the life-saving surgery only if the committee considered Alison sick enough.

Skavdahl remembers Mora saying that if he couldn’t secure the approval, he planned to send Alison in an ambulance 90 miles south to Seattle, a drive that can take well over two hours on the congested highway. “And I’m just thinking, ‘What? You have to get a bunch of people together?’” Skavdahl recalled. “And he goes, ‘Well, it’s not quite as bad as it sounds. I can get them on the phone, it’s not like they all have to get here, but I don’t know how long it will take.’”

It’s unclear from the records how long the committee deliberated, but Alison said it felt like around an hour. “I remember being scared about that,” Alison said. “You’re telling me this is really serious and that my life is in danger, and we have to wait, and these people have to say it’s OK for you to have this procedure you absolutely need.”

Mora’s notes show that the ethics committee approved the surgery because of the risk to Alison’s health. At some point, records indicate she was given misoprostol to soften her cervix. But before she made it to the operating room, Alison miscarried into the toilet. She felt so sick that she thought she might be hallucinating when she saw the white form in the water. She sobs recalling it, six years later.

“I didn’t have to suffer like that,” Alison said through tears during an interview in June. “Everyone deserves adequate medical attention, and information, and choices.”

Alison and her husband said that besides Mora, no one at St. Joseph mentioned the possibility of surgery to end Alison’s pregnancy. She said providers “ignored that whole area,” and neglected to do a vaginal exam, even as they ran tests on her abdomen and chest. During her final visit to the ER, Alison, having searched online for possible causes of her pain, said she asked a doctor if it might be a uterine infection; she said the doctor wouldn’t make eye contact and told her to talk with her OB-GYN. Mora and PeaceHealth declined to comment on Alison’s case. The Catholic health system directed Rewire.News to its statement of common values, which says it “strives to promote the sanctity of all human life.”

“Our care embraces women and their children both during and after pregnancy,” the statement reads. “Because we believe in the sacredness of life’s journey from conception until natural death, direct abortion is not performed in any PeaceHealth-owned, operated or leased facilities.”

But Alison believes her life was put at risk.

“If I had been in an ambulance in traffic for hours, I really could have died,” Alison said. “I feel lucky that I didn’t die.”

Washington lawmakers have enacted some of the country’s most progressive policies to protect reproductive health care. But these measures have run up against the state’s high concentration of religious facilities like PeaceHealth, which are unwilling to carry out the legislature’s mandates. Washington state has the third-highest concentration of Catholic hospital beds in the country, according to the most recent MergerWatch report from 2016. Doctors and advocates told Rewire.News that it’s not uncommon for miscarrying patients to have their care dangerously delayed or be forced to travel, sometimes dozens of miles, because of the ban on abortion in Catholic facilities.

Washington law has long declared birth control and abortion to be a fundamental right and required public hospital districts that provide maternity care to provide abortions. Last year, legislators passed a law requiring insurance plans to cover abortion if they cover maternity services. But Washington, like nearly all states, also has policies that allow institutions and providers to refuse to perform abortions. A decade ago, Washington voters legalized death with dignity—but as with abortion, many hospitals, including Catholic ones, refuse to offer it. Meanwhile, the Trump administration has moved to empower hospitals to deny care on religious grounds and has sided with providers who refuse to participate in abortion care.

Some Catholic hospitals in the state also have imposed blanket bans on insurance coverage for gender-affirming services; Pax Enstad, a transgender teenager, sued PeaceHealth after the company denied him coverage for top surgery in 2016. This year, Washington lawmakers passed a ban on these blanket denials that takes effect in January. The Reproductive Health Access for All Act also required all hospitals to fill out a checklist designed by the state health department to publicly disclose on the department’s website which specific reproductive health services they offer. As of September 24, 72 of the state’s 95 hospitals had submitted their forms in compliance with a September 1 deadline, a department spokesperson told Rewire.News. “We will begin citing hospitals during our routine on-site compliance surveys if the new reproductive health services form has not been submitted,” the spokesperson said.

But these progressive laws have so far not stopped Catholic hospitals from denying care to patients like Alison. And mergers and affiliations have expanded the influence of Catholic health systems in a state known for its relatively progressive politics.

“When I first moved here, I didn’t even fully understand or essentially believe—because it’s such, in some ways, a progressive and liberal state—that there could be such restrictions on care when it came to things like miscarriage management,” Leah Rutman, health care and liberty counsel at the ACLU of Washington, told Rewire.News. “As I started to hear story after story after story I was horrified by the fact that all these great laws can exist on the books and there can be such a feeling of access to care … but people and women can still be in emergency situations and not get the care they need.”

 “This Is Not a Rare Event”

A few years ago, Dr. Brigit Brock, a maternal fetal medicine specialist, was working at her outpatient consultation clinic in Everett, about 30 miles north of Seattle, when a patient arrived in preterm labor. At 20 or 21 weeks pregnant, before the fetus is viable, the patient’s cervix was open; her amniotic sac and parts of the umbilical cord were in the vagina, Brock told state lawmakers last year. She was testifying in favor of a bill—which failed to pass amid opposition from hospitals—that would have prohibited health-care entities from limiting the ability of a provider to give patients comprehensive information and to provide services when the failure to do so would put the patient at risk. (A weakened version of the bill failed to pass again this year.)

The patient needed to be hospitalized immediately, Brock said. So she and her colleagues sent her to Providence Regional Medical Center Everett, a Catholic hospital attached to Brock’s outpatient clinic.

But the labor and delivery nurse told the patient and her husband that the Catholic hospital didn’t participate in abortions, Brock told lawmakers. “She’s in pain and this is a devastating thing for them to go through, and they were not allowed even to step onto the labor and delivery floor,” Brock said. When the patient returned to the outpatient clinic, Brock knew that if she called an ambulance, it might take some time to arrive and would likely take the woman back to Providence. So she told the patient’s husband to drive her to Swedish Medical Center in Seattle, which would take up to an hour in traffic.

Dr. Nari Heshmati, the former chief of obstetrics at Providence Everett, said in an interview that he didn’t remember the specific case Brock described, although Brock recalled that he was involved. He said that hypothetically, in a case where a patient showed up with those symptoms, the protocol would be to transfer the patient to Swedish for more advanced care than Providence Everett can offer. In a written statement, the hospital declined to comment on specific cases, saying, “Each patient’s unique needs are evaluated on a case-by-case basis, and all treatment decisions are made privately between our patients and their care teams.”

But Brock said it’s not the only time she’s seen this kind of case. “People think this is a rare event. This is not a rare event. This happens frequently,” she told lawmakers. Brock often works at Swedish Medical Center in Seattle, where she told Rewire.News she sometimes “rescues” patients from Catholic hospitals in surrounding communities by pulling them into the Swedish system.

Like many non-Catholic hospitals, however, Swedish is partly subject to the Catholic rules. That’s because it affiliated with Providence in 2012 and agreed to stop performing abortions unless there is a threat to the patient’s life. Brock said that in her experience, Swedish typically trusts doctors to make this call. “If we say, ‘Hey, this is life-threatening,’ we don’t get a lot of pushback,” she told Rewire.News.

The Unexpected Consequences of a Delay in Care

It’s not always easy for staff in Catholic hospitals to decide when a pregnancy is life-threatening enough to merit action—as Meghan Eagen-Torkko’s story shows.

In 2004, Eagen-Torkko was about seven weeks pregnant when she had an incomplete miscarriage. She worked as a labor and delivery nurse at Providence in Everett, and her insurance covered her only at that hospital. Her debacle shows how the laws promoting abortion and contraception access in Washington can be blunted by religious facilities; if insurance plans only cover Catholic options, comprehensive coverage of reproductive health services won’t help. (Her former employer, Providence, recently announced it planned to enter the health insurance exchange in Washington state and invoke its religious principles to limit coverage of abortion.) There was no other high-risk obstetrics facility in the area, Eagen-Torkko says. Like Alison, Eagen-Torkko’s only option when she was bleeding and needed urgent care was a Catholic facility.

As a nurse, Eagen-Torkko knew she needed a procedure called an aspiration to remove the remaining tissue from her uterus and stop her bleeding. But care providers at Providence were worried that her fetus might still have a heartbeat. For hours, they performed ultrasound after ultrasound, searching for a heartbeat that wasn’t there, afraid to get in trouble if they missed it. After about six hours, they finally performed an aspiration. During this ordeal, Eagen-Torkko lost enough blood to require a transfusion.

The consequences of this transfusion would become apparent later, when Eagen-Torkko was pregnant again. She had been transfused with blood containing an antigen called Kell. While Eagen-Torkko, like most people, was Kell negative, her ex-husband was Kell positive—as were her pregnancies. Because she was sensitized to Kell by the transfusion, her body produced antibodies that put her next pregnancy at risk of sudden fetal demise. Doctors told her that her fetus could die with no warning and no way to predict it. “It’s a very hard position to be put in knowing that your body could essentially kill your baby, which is what happens with Kell,” Eagen-Torkko told Rewire.News. 

Eagen-Torkko dissociated from the pregnancy, declining to buy anything for her daughter until she was about 30 weeks pregnant. While she had planned for a vaginal birth, when her daughter started showing signs of stress once she was far enough along to deliver, her Kell status made Eagen-Torkko more inclined to accept her doctor’s recommendation for a C-section, she said.

Years later, Eagen-Torkko, who is now a midwife, said she doesn’t blame her providers, who might have been afraid to get in trouble or lose their admitting privileges. But she said her case shows how hard it is to apply religious doctrine to real-life crises.

“I don’t think people understand how gray this is and how everybody is cobbling things together sort of on the fly,” Eagen-Torkko said. “I think we’re setting up this idea that there is some sort of a clear, bright line between life-threatening and non-life-threatening and it just doesn’t exist.”

“A Very Narrow Definition of Protecting Life”

There are 39 hospitals in Washington that are federally designated critical access facilities, which typically means the nearest alternative is more than 35 miles away. At least six of those hospitals are Catholic, a Rewire.News analysis found. On San Juan Island, off the coast of Bellingham, PeaceHealth runs the island’s only hospital, meaning patients have to travel by boat or air to get to another option. In Centralia, a city of 16,000 south of Olympia, the sole community hospital—another, similar federal designation—is Catholic. For patients in these communities, there is no accessible option not restricted by religion. In fact, Alison had to return to St. Joseph to deliver her son two years after her ordeal, because it remains Bellingham’s only hospital.

Even more of the state would likely be under Catholic health-system control if not for grassroots efforts over the years to fend off mergers. In Skagit County, between Alison’s hometown of Bellingham and Seattle, activists formed People for Health Care Freedom and helped defeat a series of affiliations that threatened to leave Washington with only Catholic hospitals from Seattle to the Canadian border.

Their concern was well founded: The Church sees mergers with secular systems as a way to spread its religious message. “New partnerships can be viewed as opportunities for Catholic health care institutions and services to witness to their religious and ethical commitments and so influence the healing profession,” the Catholic Bishops wrote in the 2009 edition of the Catholic Ethical and Religious Directives. “For example, new partnerships can help to implement the Church’s social teaching.”

Buckling down on their enforcement of this teaching in their latest version of the directives, the Bishops tightened the rules for mergers and partnerships, emphasizing that a Catholic institution must “ensure that neither its administrators nor its employees will manage, carry out, assist in carrying out, make its facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.” That means even institutions that are secular, like Swedish in Seattle, may be required to adopt Catholic restrictions.

But Washington’s policies intended to address this wave of Catholic mergers have inadvertently revealed concerns about secular facilities too. In 2014, Gov. Jay Inslee (D) mandated that all Washington hospitals disclose their reproductive health-care policies on their websites and the health department website. When Hilary Schwandt, an associate professor at Western Washington University, reviewed these policies in 2016, she found very little concrete information. “Most hospital reproductive health policies, regardless of Catholic affiliation, provided more confusion than clarity in terms of abortion and contraception service provision,” Schwandt and her colleagues wrote in a report.

Even among non-Catholic hospitals, only 13 percent said they provided both medically and non-medically indicated abortions. One non-Catholic hospital had an approval process for abortion that required “at least six individuals from the hospital, paperwork on behalf of the patient and the provider, a minimum waiting period of 48 h[ours], and a social service referral,” researchers found. Another required 11 hospital personnel and 13 hospital procedures before it would allow a medically indicated abortion. In an interview with Rewire.News, Schwandt attributed these restrictions to the pervasive stigma against abortion and reproductive health-care across all medical facilities.

Like Alison, Schwandt lives in Bellingham. After concluding her research, she said she’s unsure where she would tell a friend to go if she were miscarrying. “To be honest, I would be really afraid to go anywhere,” she said. In March, Schwandt testified in favor of legislation—later incorporated into the Reproductive Health Access for All Act, signed by Inslee in May—that requires hospitals to disclose their reproductive health-care services on a form developed by the state. In line with Schwandt’s recommendation, the state designed a checklist of services like abortion and emergency contraception that should make it harder for hospitals to release only vaguely worded policies. The law doesn’t outline specific penalties, leaving enforcement up to the health department.

For Alison’s mother, Steffany Raynes, this transparency is only a first step toward preventing what happened to Alison from happening again.

“I want PeaceHealth and other Catholic hospitals to have to disclose what their policies are, and limitations, and make available appropriate care for women who might want to make different choices,” Raynes told Rewire.News. “I don’t want anybody to have to die because of a very narrow definition protecting life.”