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The vast majority of abortions in the United States are performed in specialized clinics dedicated to abortion care. But the most urgent procedures, when abortion is necessary to protect a patient’s health or save their life, usually take place at a hospital.

While the strict regulations around abortion at Catholic hospitals are widely known, a groundbreaking report published Tuesday by Columbia Law School shows that many Protestant-based and secular hospitals in the South also impose harsh restrictions on abortion care, permitting the procedure only under a narrow set of circumstances and sometimes requiring an elaborate approval process that may involve religious leaders, even in time-sensitive cases when a patient’s life might be in danger.

Strict restrictions have become a “generalized standard of care” at many Protestant and secular hospitals, said Elizabeth Reiner Platt, the director of the Law, Rights and Religion Project at Columbia and a co-author of the study, which was based on an analysis of abortion restrictions at Protestant hospitals and survey responses from more than 200 doctors.

These findings have surfaced as abortion care faces its greatest threat since before Roe v. Wade. On Dec. 1, the U.S. Supreme Court will hear a case out of Mississippi that could eliminate a pregnant person’s constitutional right to an abortion. If Roe does fall, high-risk patients unable to secure timely care at hospitals may have nowhere to turn.

“Folks often think that, post-Roe, these kinds of emergency medical situations will just be done in the hospitals,” said Platt. “But we really don’t want these decisions left to the mercy and the whim of these providers working in really restrictive settings.”

Restrictions on abortion help to build trust between a hospital and a community, said Ingrid Skop, a practicing OB/GYN and a member of the American Association of Pro-Life Obstetricians and Gynecologists. “People need to trust a hospital to have the needs of its patients as its primary concern,” including the mother and the baby, she said. If the hospital where she works in San Antonio started performing elective abortions, she said, “it would be upsetting to the public.”

All hospitals detailed in the report, where information was available, allow providers to perform abortions in life-threatening situations, Platt said. But the language around those exceptions is often vague, she added, with providers left to guess just how risky a situation has to be before they are permitted to perform an abortion. Throughout the report, several doctors describe instances in which a patient’s water broke before the pregnancy was viable, leaving the patient at risk of infection. Still, the report said, this situation sometimes didn’t “count” as life-threatening.

“It varies based on hospital culture and the particular provider involved,” Platt said. “There is no light that turns on when someone is in a life-threatening situation.”

These vague exceptions may be intimidating to doctors who fear what might happen if they perform an abortion later deemed unnecessary by various medical and legal authorities, a dynamic that has already started to play out in Texas, where abortion after approximately six weeks’ gestation has been banned since Sept. 1. Although the Texas law includes an exception for a “medical emergency,” according to hotline workers with the National Abortion Federation, doctors have turned away at least one patient with an ectopic pregnancy, a life-threatening condition in which a fetus grows outside the uterus, and instructed her to seek care in another state.

Protestant hospitals vary widely in when they allow abortions to be performed, according to the report. On the more restrictive end of the spectrum, the Baptist Health System in San Antonio, which did not respond to a request for comment, permits abortion only when it is “medically necessary to avert … a serious risk of substantial and irreversible physical impairment of a major bodily function, other than a psychological condition.” Other definitions are more inclusive, allowing abortions under circumstances that could impact a mother’s physical or mental health.

The report also found that some hospitals avoid raising abortion as an option in counseling sessions with high-risk patients or patients with fetal anomalies.

“It’s embedded in the culture: You don’t talk about abortion,” said Sara Pentlicky, an OB/GYN based in Philadelphia, who was interviewed for the report and worked for four years at a secular hospital in the South that is “closely affiliated” with a Baptist hospital. Throughout her time there, she said she rarely heard other doctors talk about abortion. In a conservative state, she added, many of her patients made it clear they had no interest in the procedure.

Top leadership can impact a hospital’s antiabortion culture. A hospital’s governing principles and regulations — including any major financial, medical and ethical decisions that arise — are often determined by a board of trustees. In her research, Platt discovered that a portion of these trustees at Protestant hospitals are sometimes selected by religious institutions. The report uncovered 17 cases in which religious organizations, like the state Baptist conventions or Methodist conferences, were responsible for naming at least one of the trustees. In one case, at the Baptist Memorial Health Care system, the entire board was selected by the Baptist conventions for Arkansas, Mississippi and Tennessee. (The Baptist Memorial Health Care system did not provide a comment for this story.)

To make decisions about individual cases that might necessitate abortions, the report found that some hospitals, both Protestant and secular, rely on “abortion committees.” These groups can include selected doctors and attorneys and sometimes religious leaders. At Skop’s hospital in San Antonio, the approval committee includes three OB/GYNs and a chaplain, who consults with the patient, she said.

“Whether the woman is secular or religious, this is a spiritual crisis that a desired baby is likely to die,” said Skop. “Addressing her spiritual needs regardless of religious status is important.”

Skop said the approval process at her hospital can happen in under an hour. But other doctors quoted in the report describe a much more drawn-out procedure. The time required to obtain approval prevents some patients from receiving the care they need, according to the report.

One doctor who spoke to the authors recalled a patient with kidney disease who was referred to his hospital by an abortion clinic, where abortion providers weren’t comfortable performing the procedure for such a high-risk patient. Because the patient was near the gestational age limit for abortion care in Texas, the doctor said in interviews, the hospital could not approve the procedure in time. The hospital told the patient she could either continue her pregnancy, the doctor said, or seek an abortion elsewhere.

Pentlicky had similar experiences when she worked in the South, she said. Any provider who wanted to perform an abortion had to go through “a million hoops,” she said, appealing to higher-ups with written letters. In the four years she worked at the hospital, she remembers only four abortions being performed.

“The messaging was always: ‘We don’t do abortions here,’ ” she said.

If Roe falls, and abortion clinics throughout the South are forced to close, she added, high-risk patients may have no choice but to stay pregnant.

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