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The Supreme Court on Tuesday ruled that crisis pregnancy centers — which use deceptive language to block women from accessing contraceptives and abortions — are protected by free speech laws. In a 5-4 decision, a group of all-male justices struck down a California law requiring the centers to notify patients that California provides free and low-cost medical services, including abortions.

All over the country, these clinics openly lie to patients about what services they offer, often preventing women from making fully informed decisions about their reproductive health. But they’re not the only health-care providers withholding information in this way. Catholic hospitals and affiliated doctors’ offices have long had religious limitations on the reproductive health care they offer — and their patients may have no idea.

All Catholic-owned and affiliated medical facilities in the United States follow some form of Catholic Ethical and Religious Directives, which prohibit certain types of care deemed immoral by the Catholic Church. In their strictest form, they prohibit all forms of birth control and only allow doctors to recommend natural family planning for heterosexual couples. In reality, the rules play out differently across the country, depending on interpretations by local Catholic bishops, decisions made by hospital ethics committees, and the willingness of individual doctors to bend the rules.

“Some doctors are more likely to say, ‘wink-wink, you have acne, let’s give you this birth control,’” said Maryam Guiahi, an obstetrician-gynecologist and assistant professor at the University of Denver. But those providers may still be limited to birth control options with other medical indications, meaning ones that could be reasonably prescribed for something other than birth control. “If someone doesn’t want a hormonal method, the best thing for her to get is a copper IUD,” Guiahi explained, referring to an intrauterine device. “But she’s not going to get that at a Catholic institution.”

The restrictions can put women’s lives in danger. Over the past few years, numerous women have come forward with stories of being turned away by a Catholic hospital while facing pregnancy complications. In one case, a woman’s water broke after 18 weeks and the hospital refused to treat her, even though the pregnancy was no longer viable, until she came down with an infection. In another case, a hospital refused to end a woman’s unviable pregnancy for two months until she nearly bled to death.

“They’re literally letting you get sick before they take care of you,” Guiahi said.

Research shows that women care about the restrictions a religious institution might put on their health care, but they don’t realize it could already be happening. When researchers Debra Stulberg, family medicine specialist and professor at the University of Chicago, and Lori R. Freedman, a medical sociologist at the University of California, polled 1,430 American women of reproductive age, only one-third of them said they cared if their hospitals were religious. But when the women were told some hospitals can restrict care based on religion, 80 percent said they wanted to know about those restrictions.

The feedback was similar across differences in race, religion and political affiliation, according to Freedman.

“Women really wanted to know about restrictions on care,” Freedman said. The problem is that hospitals aren’t required to disclose what care they aren’t providing, and it’s incredibly difficult for patients to know how their options might be limited.

When Stulberg and Freedman conducted another national survey of women ages 18-45, over a third of the women who named a Catholic hospital as their primary hospital didn’t know it was Catholic.

In another recent study, Guiahi instructed mystery callers to contact 144 Catholic-affiliated obstetrics and gynecology clinics across the United States and ask about birth control. Ninety-five percent of the clinics agreed to schedule a general birth control appointment. But when the callers then asked about specific birth control options, 32 percent of hospitals said they wouldn’t insert copper IUDs and 42 percent said they didn’t offer tubal ligation.

“A birth control appointment should include all birth control options,” Guiahi said. “You shouldn’t have to specify, but it turns out you do.”

Not only do the ethics restrictions vary greatly from hospital to hospital, but it can be incredibly hard for patients to even know whether their hospital is Catholic. Many modern Catholic hospitals don’t have obvious Catholic names — like Saint-Mary’s or Sacred Heart — nor nuns walking the hallways, or any other clear indication of their religious bent. For example, Dignity Health system is one of the largest Catholic hospital systems in the country, but it takes a close read of its website to find mentions of religion (and prescribing birth control IS listed as part of the OB-GYN services offered). On the other hand, Mount Sinai St. Luke’s in Manhattan, which has “saint” in the name, isn’t Catholic at all.

Approximately 15 percent of acute care hospitals in the United States are Catholic-owned or affiliated, but the guidelines also impact clinics and offices associated with Catholic hospitals. In many cases, doctors practice in office spaces that are rented from large hospital networks, meaning routine check-ups and birth control appointments could fall under Catholic rules. A recent investigation by Columbia Law School showed that in 19 of the 34 states studied, women of color are more likely than white women to give birth at hospitals that follow such restrictions.

Brian Fenmore, an OB-GYN with admitting privileges at Tarzana Medical Center in Los Angeles, said he pushed back against Catholic directives when the hospital was bought by Providence, a Catholic network, 10 years ago. At the time, his office was on hospital grounds, meaning he wouldn’t have been allowed to keep prescribing birth control to his patients. With the help of lawyers who threatened legal action, Fenmore said he was able to break his lease and move his office across the street.

Fenmore also joined the staff at a nearby non-Catholic hospital in order to provide his patients with a greater range of reproductive care options, like getting their tubes tied. But he said individual doctors can’t fix the problem on their own.

Mergerwatch, an organization that tracks hospital mergers, estimates that 46 U.S. Catholic hospitals are sole community providers. This means that people seeking emergency care at these facilities can’t just go elsewhere if the Catholic ethics restrictions limit their options. (Crisis pregnancy centers count on scarcity, too; by the time a patient is seen at one, and discovers that an abortion won’t be performed there, she may be out of time to find a legitimate provider she can access.)

“The hospital should have to advertise what services are available and not available, and the doctors should tell patients, ‘I’m in a facility with religious bylaws,’” Fenmore said. “These conversations have to occur before there’s an emergency.” Fenmore estimates that 90 percent of his patients aren’t aware of Tarzana’s limitations.

In the meantime, Catholic health-care restrictions are likely to continue growing. Catholic-owned hospitals often write religious ethics restrictions into the terms of the deal when they merge or partner with other facilities, even secular ones. According to a 2016 report from the American Civil Liberties Union, 1 in 6 hospital beds in America are subject to Catholic restrictions. Experts who track hospital mergers predict several more big mergers in the next few years, and the Trump administration has shown itself particularly amenable to religious exemption laws.

At the beginning of this year, the administration created a new conscience and religious freedom division within the Department of Health and Human Services in order to make it easier for health-care providers to decline to care for patients for religious reasons. The department has proposed policy changes that will likely give individual health care practitioners — not just the entities that employ them — greater leeway to refuse to provide abortions, birth control or fertility treatments.

“They’re only going to change when people stop going to them,” Guiahi said of Catholic ethics guidelines. “They have to start hearing that women are upset.”

And as for the crisis pregnancy centers? As of Tuesday, they can’t be compelled to inform patients about alternative affordable abortion and contraception services offered by state agencies. But women still have the opportunity to voice their concerns in other ways, whether it be through protest, voting or other public advocacy work. Our reproductive rights depend on it.

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