The Catholic Ethical Directives and How They Drag Ob/Gyns Down

This article feels more personal than the others. I’ve been sued. I’ve been sent to peer review. I’ve had my glasses kicked off my face by a woman in labor. Right or wrong, it’s all part of everyday business as an Ob/Gyn.

But I’ve only been called evil to my face by the Catholic church.

Over… birth control.

Let’s go back to the beginning. In 2015, I joined a lovely private practice fresh out of residency. We rented office space from the Catholic hospital where we delivered our patients, Covenant Medical Center. I had been warned. A dear professor from my residency had told me never to work for a  Catholic employer – they would make you sign a piece of paper full of promises you couldn’t keep, that you would never talk to a patient about abortion, never prescribe birth control, and you would abide by the most conservative interpretation of Catholic doctrine at all times.

But I wasn’t too worried. For one thing, the hospital had a longstanding “workaround” – the C-section rooms on Labor and Delivery were, on paper, a whole different hospital! It was called the “Schoitz Hospital,” after a now defunct institution that had merged with Covenant decades earlier. Legend has it that when the Schoitz Hospital board approved the merger with Covenant, they were worried women would no longer have access to tubal ligations, so they insisted on this workaround, and Covenant promised they would find a way to continue to provide these services. It led to some funkiness. We even performed our laparoscopic tubal ligations in those C-section rooms, which was sometimes less than ideal. But it worked.

Besides, the order running our little hospital had a reputation for being “cool nuns.” Rumor had it that they didn’t give a rat’s ass if we prescribed birth control and tied our patients’ tubes – their mission was to provide health care to women in need, simple as that.

As the years went by, a few things changed. The Wheaton Franciscan Sisters were getting older and older, and they no longer had the capacity to run a whole hospital system. They sold their little affiliated group of hospitals to the larger MercyOne system in 2016.

Whoa. This was a whole different ball of wax. MercyOne was itself owned by a larger conglomerate, Trinty Health of New England, which was in turn owned by the massive behemoth Catholic Health East,  and our marching orders were now dictated by faceless bureaucrats in Waterbury, Connecticut.

Meanwhile, as Catholic hospitals acquired more previously secular hospitals and practices, often with similar “workarounds” to our Schoitz rooms, the United States Conference of Catholic Bishops took note and in 2014 had voted to make it a policy to find and eradicate these workarounds.

At some point, our local bishop (of the Archdiocese of Dubuque) heard about our hospital. He heard that we were tying patients’ tubes in the C-section room. He heard we were giving Depo Provera to patients before discharge. He heard that Nexplanons and IUDs were being placed by the midwives in the hospital-owned clinic.

He brought the hammer down on us.

I remember the meeting in August 2018 where we were summoned to discuss the Catholic Ethical and Religious Directives – a document that lays out how sinful and frankly “evil” the Catholic church finds every method of contraception to be other than cycle timing and how no contraception can be allowed in any Catholic health care facility.

It was the most bananas meeting I had ever been to.

This meeting, for all Ob/Gyns and midwives who held privileges at Covenant, was led by a coterie of pinched-faced, mean middle-aged white women with some official title like “culture liaisons” but whom I thought of as “Catholic enforcers.” They were true believers hired by Catholic Health East to stamp out any immoral contraceptive goings-on in its hospitals.

They had a PowerPoint presentation. It cut right to the chase. Around slide 3 or 4, they informed us that sterilization was an act of the greatest evil. Likewise, an IUD was considered “temporary sterilization” (contradiction in terms notwithstanding) and, similarly, evil of the highest order.

There would be no more tubal ligations at Covenant, with or without C-sections, under any circumstances. The hospital-owned practice would no longer be placing IUDs or Nexplanons or providing contraception of any kind. Our independent practice would no longer be allowed to place IUDs under anesthesia.

At the same time, my practice had just announced it was closing, and I had chosen to work for the secular hospital across town, my former professor’s words ringing in my ears.

My phone started buzzing. Everybody in the room was texting me – “Can you get me a job at your new hospital?”

I wished I could.

A website called the Rewire News Group published an article about that time. As you can see, we were all pretty mad. Except for the one super Catholic midwife who had always scrubbed out during my C-sections with tubals so she wouldn’t have to hold the Babcock clamp and participate in sin. (That was before salpingectomies at time of C-section, you guys. You should have seen us struggling with very long free ties of 0 plain gut.)

Almost nobody wanted to work under these conditions, which we considered grossly offensive to us and our patients. Many of my former colleagues left. Some went to the University of Iowa, some retired early, and some moved out of state. It caused a crisis of Ob/Gyn access that Black Hawk County, Iowa is still reeling from.

Many patients left. Many of my patients followed me to my new job, and many others just came over to get their birth control. MercyOne Waterloo’s “Last Day of Depo” will always live in my memory. I think it was April 2019 – the day after which no more Depo Provera would be given in clinic. I remember our fax machine just whirring away all day long as more and more patients’ records transferred over. All these poor ladies wanted was their damn Depo! Well, easy annuals for us.

Then, years later, I was out to dinner with a colleague.

Had I heard that MercyOne was putting in IUDs again? She asked.

What?! I said. That’s great news! I am so happy for the patients. How did this happen?

Well, it turns out that the hospital’s Family Medicine Residency was in danger of losing accreditation, since placement of LARC is part of the family medicine residency requirements. So patients were allowed to get IUDs and Nexplanons, if they were placed by family medicine residents under the supervision of a doctor or midwife for their education.

So let me get this straight, I said. When the only person who benefits from birth control is a woman – who wishes not to become pregnant, or not to suffer from heavy, painful periods – it is a terrible sin, one of the worst, and it is not to be tolerated. But when the person who benefits from the same birth control is a man  -- say, a family medicine resident, who wishes to complete an accredited residency – then that same birth control can be deployed for his sake, and maybe it’s OK to be a little evil.

The hypocrisy. Just allow it to blow your mind for a moment.

Let’s say it again, for those in the back. All this was never about some vague concept of “protecting life.” It’s about controlling women.

Waterloo’s story is not the worst one. It devastated the practice, but there are other places in town, including a whole other hospital, where patients can get their tubes tied or any other birth control they need.

There are plenty of other communities in this country where the Catholic hospital is the only game in town. And Catholic hospitals are increasing their footprint.

Why do we allow this to happen? Why are they allowed to bill the global fee for OB care when they don’t provide a key component of postpartum care, contraceptive counseling? Why are they allowed to bill the full annual exam fee when they don’t provide a key component of well woman care, contraceptive counseling? Why aren’t Catholic hospitals penalized by government and private payors for their absolute dereliction of duty to their patients, in failing to provide or even discuss the one inexpensive, safe, widely available medical intervention that has saved millions of women’s lives and lifted millions of women and girls out of poverty - contraception?

I had kind of hoped that ACOG would talk to the Biden administration about this when he was elected in 2020. But ACOG has other fish to fry. Someday, I hope there is a movement to penalize these health care entities for willfully withholding contraception. I’ll start it. Write me if you’re in.

Otherwise, if you made it to the end of this article, thanks for listening to my story.

Karla Solheim, MD, FACOG