Catholic Directives and Maternity Deserts: The Double Whammy Facing Iowa’s Moms-to-Be

What do you get when you cross a state that’s losing its birthing hospitals at an alarming rate, with more and more restrictive Catholic health systems?

You get women driving very long distances to both have their babies and get their tubes tied at the same time, sometimes putting themselves and their babies at risk.

Map of Iowa’s birthing hospitals, overlaid with hospitals where women are not permitted to get tubal ligations due to Catholic rules

One of the most fundamental services we provide as Ob/Gyns is a C-section with a tubal ligation. For a woman who is sure she doesn’t want any more children and needs a C-section to safely deliver her child for whatever reason, the C-section is the perfect time for her also to get the permanent birth control she desires. When we deliver babies by C-section, we are literally looking at the fallopian tubes, right there next to the uterus. It is safe, quick, and easy to tie (or remove) a woman’s tubes after the baby comes out. As long as a woman is sure she has no desire to have any more kids in the future, it can save her from having to have an additional abdominal surgery, and it also frees her from having to worry about birth control ever again.

Tubal ligations are common – in fact, female sterilization is the most common form of contraception in the United States , according to the CDC. 39% of American women aged 40-49 have had their tubes tied or removed.

Yet for reasons I do not understand, the Catholic Church has decided tubal ligations are sinful and refuses to let them be performed in many hospitals it owns. In many cases, the Catholic hospital is the only one in town – or in the county, which makes life more difficult for women who are unlucky enough to live near them.

Of course, tubal ligations are not right for every woman. If there is just a tiny chance a woman might want another baby in the future, I would not recommend this permanent and irreversible surgery.

HOWEVER, for women who do want them, they are life changing. They can even be life saving, for women whose lives would be endangered with another pregnancy. Some women will travel long distances just to be able to get their tubes tied, because they simply want to be reassured they will never have to become pregnant again.

But when a woman goes into active labor, it’s a VERY inconvenient time to drive long distances.

This map puts it in perspective.

While many labor units have closed their doors in Iowa over the past decade, everyone in Iowa at least has a birthing hospital with the ability to do a C-section in the next county over.

But that hospital may not allow them to get their tubes tied.

So a woman in labor has to make a gamble – does she go to the closest hospital, where she will have to get another surgery in 6 weeks to tie her tubes? (Average cost of laparoscopic salpingectomy at Allen Hospital, Waterloo: $11,267) Or does she drive a little further and cross her fingers, so she can get her tubes tied with her C-section? In some cases, if a woman has a complicated pregnancy, does she deliver at the urban Level 2 birthing hospital that won’t tie her tubes? Or does she gamble and go to the Level 1 rural hospital that doesn’t have all the advanced equipment but, again, will let her have the tubal ligation she wants? These are decisions Iowa women are faced with for absolutely no good reason but the whim of a Catholic Bishop.

In fact, the birth control policies that all women in these counties have to live by are set by the Bishop that rules over the Catholic Church in their part of the state. Depending on the Bishop, these policies can vary. Iowa is divided into 4 dioceses: Diocese of Sioux City in Northwest Iowa; Diocese of Des Moines in Southwest Iowa; Diocese of Davenport in Southeast Iowa; and Archdiocese of Dubuque in Northeast Iowa.

You may be surprised to find this out, because the hospitals are in no hurry to publicize their policies. You will not find it on their websites. They know this policy is deeply unpopular, so although they enforce it strictly, they do not want to talk about it. I had to use my network of Ob/Gyns around the state to find out the tubal policies of all these hospitals, because this information is so hard to come by for the public.

Here are the Catholic hospitals where women are not allowed to have a tubal ligation at time of C-section – and a few where they are:

MercyOne Mason City (Cerro Gordo County) – Women are not permitted to have tubal ligations with their C-sections. According to a former doctor there, if a woman wanted to have her tubes tied, she would simply have a second surgery after her C-section. “She would have a second anesthesia and a second cost, which the patients shouldn’t have to have,” said this doctor.  “I think it makes it harder to recruit [physicians].”   As a side note, to me the rankest hypocrisy at MercyOne Mason City is that they don’t permit tubal ligations but also don’t permit VBACs. Since it is dangerous to get pregnant after 3 C-sections, they frown on birth control, and they also require women who have had one C-section to have another one in every subsequent pregnancy… what do they expect women to do? Just die from placenta accreta?  

Geographically, the tubal restrictions in Mason City are particularly devastating for patients – MercyOne Mason City is the only Level 2 birthing hospital for an entire 9-county area.

Black Hawk County: MercyOne Waterloo – Women are not permitted to have tubal ligations with their C-sections. This is less devastating for women, because there is another Level 2 birthing hospital in Waterloo – Allen Memorial – where tubal ligations are allowed. However some employer-provided health plans do require women to delivery at MercyOne… in which case, they are out of luck.

Dubuque County: MercyOne Dubuque  - Women are not permitted to have tubal ligations with their C-sections. Again, fortunately there is another Level 2 birthing hospital, Finley, in Dubuque where tubal ligations are permitted.

Carroll County: St. Anthony Regional Hospital in Carroll – Women are not permitted to have tubal ligations with their C-sections. This is a little more tragic because not only is St. Anthony the only hospital in Carroll County – for women in adjacent Guthrie County, where there are no maternity services, if they wanted a tubal ligation with their C-section, they would have to drive two counties over to reach a birthing hospital that offers one.

Linn County: MercyOne Cedar Rapids – Women are not permitted to have tubal ligations with their C-sections. As in Waterloo, there is a secular hospital in Cedar Rapids (St. Luke’s) where women are allowed to get tubal ligations.

Polk County: MercyOne Des Moines and MercyOne West Des Moines – Women are not permitted to have tubal ligations for any reason with their C-sections. Although there are three other birthing hospitals within the Des Moines metro area, this can still cause problems for patients. I spoke with an Ob/Gyn in an outlying hospital who transferred a patient to MercyOne Des Moines for a higher level of care due to preterm pre-eclampsia. Although the patient was planning a tubal ligation, MercyOne Des Moines refused to honor her request for a tubal ligation with her C-section, and the patient had to have a separate surgery at a later date for her tubal ligation in her home hospital.

Clinton County: MercyOne Clinton – Women are not permitted to have tubal ligations with their C-sections for any reason. I spoke with an Ob/Gyn in Davenport who told me that many women make the drive from Clinton to Davenport for their deliveries so that they can get tubal ligations. She states that in winter, especially, the extra driving distance can be dangerous. She states she also sees a number of patients who get unnecessary second surgeries after their C-sections in Clinton in order to have their tubal ligations.

Scott County: Genesis East in Davenport – Interestingly enough, although this hospital is owned by the MercyOne system, which forbids women from getting tubal ligations in all their other Iowa hospitals, women are allowed to access the full range of birth control, including tubal ligations, at Genesis East. A Davenport Ob/Gyn told me that when MercyOne acquired this hospital recently, many of the Ob/Gyns threatened to quit if they were no longer allowed to perform tubal ligations, so the MercyOne system made an exception for Genesis East in order to keep its Labor & Delivery unit staffed. (Seems similar to when MercyOne Waterloo decided to allow IUDs to keep its family medicine residency open.) In any case, there is another hospital in Scott County, UnityPoint Trinity Bettendorf, where women can receive tubal ligations if desired.

Pottawattamie County: Mercy Council Bluffs. Again, interestingly, women are permitted to get tubal ligations with C-sections, although not after vaginal deliveries. According to an Ob/Gyn I spoke to, the thinking is that, since it would harm the woman to have a second surgery, the hospital finds it ethical to perform the tubal ligation with C-section. I couldn’t agree more with the decision makers at Mercy Council Bluffs on this point, and I wish more Catholic hospitals would follow its excellent example! It is odd, because I believe both this and the Des Moines Catholic hospitals are all in the same Diocese – the Diocese of Des Moines – meaning that the same bishop oversees them, so why the difference in rules? Perhaps because it is a different Catholic health corporation that owns them? (MercyOne in Des Moines, CHI in Council Bluffs.) Feel free to leave a comment if you have any insight, as I am curious. In any case, there is another hospital in Pottawattamie County, Methodist Jennie Edmondson, where women can receive tubal ligations if desired.

Would your local hospital let you get a tubal ligation if you needed one? Just some food for thought.

Karla Solheim, MD, FACOG