Contraceptive emergency: Catholic hospitals overwhelmingly refuse to provide EC.

AT LEAST FIVE MILLION TIMES this year, (1) American women will need emergency contraception (EC) to reduce the chance of pregnancy after unprotected intercourse. Whether because of a broken condom, an unplanned moment of passion or the tragedy of rape, women frequently need a second chance to prevent pregnancy. Some research indicates that EC prevents pregnancy more effectively the sooner it is taken after unprotected intercourse. (2) Because women might not get prompt appointments at other medical facilities, and EC is not yet available over the counter in most states, hospital emergency rooms play a key role in providing EC.

Americans using emergency rooms expect to be offered modern therapeutic options. They also expect that medical decisions will not be governed by religious beliefs. What happens if a Catholic hospital decides to ignore medical guidance from authorities such as the American Medical Association, the American College of Obstetricians and Gynecologists, and the United States Food and Drug Administration, (3) and instead imposes religious restrictions on the provision of EC? Ibis Reproductive Health and Catholics for a Free Choice conducted a nationwide survey in 2002 to answer this important question.

HOSPITALS SURVEYED ON EC AVAILABILITY

In order to ascertain whether and under what circumstances EC was offered by Catholic hospital emergency rooms, Ibis Reproductive Health and Catholics for a Free Choice telephoned all 597 Catholic hospital emergency rooms in the United States during one weekend in August 2002. The survey took particular care to assess the potential experience of women who need EC following rape. Statistics from the FBI show that over 90,000 rapes were reported in 2001 (4) and estimates of unreported rapes suggest nearly 600,000 more annually. (5) Not only do women who have been sexually assaulted have a compelling need for EC, but in several states the law requires that they be offered prescriptions or referrals for the pills.

CATHOLIC HOSPITALS

Catholic hospitals provide a substantial portion of all hospital care in the United States. Of the roughly 107 million emergency room visits in the United States in 2000, 15% took place in Catholic hospitals. (6) Wisconsin has the highest proportion of Catholic care, with fully 41% of emergency patients seen at Catholic hospitals. In ten other states (Missouri, Iowa, Illinois, Kansas, Michigan, South Dakota, Arkansas, Montana, Oregon and Washington) over a quarter of the emergency case-load is handled at Catholic hospitals. Access to EC has become an important public health concern as Catholic hospitals have gained market share. This problem could potentially be more acute in small communities, where many Catholic hospitals maintain virtual medical monopolies.

STATE LAWS AND REGULATIONS

Because the nation's medical authorities have established EC as standard therapy to prevent pregnancy after unprotected intercourse, emergency rooms should be required to offer EC to rape survivors. Yet several national and state-level studies have shown that rape victims are often denied information or prescriptions for EC, even at non-Catholic hospitals. (7)

In response to this problem, new laws and regulations in several states mandate the provision of or referral for EC. Three states (Illinois, Washington, and California) (8) have passed legislation mandating that rape survivors be provided with information about EC when they arrive in any hospital emergency room. Six other states (Florida, Ohio, Maryland, Kentucky, Connecticut, and New York) require or encourage emergency rooms to dispense EC to rape victims, although impose no direct mandate. Three states (Washington, California, and Alaska) allow pharmacists to dispense EC under an umbrella prescription from a licensed prescriber to anyone who requests it and for whom it is not contraindicated.

CATHOLIC DIRECTIVES

One possible obstacle to the provision of EC in Catholic hospitals has been the Ethical and Religious Directives for Catholic Health Care Services. The US bishops developed these Directives in consultation with the Vatican. Their implementation is required in all Catholic health facilities. The Directives prohibit the provision of direct abortion and voluntary contraceptive sterilization, stating that the church cannot approve interventions that "either in anticipation of the marital act, or in its accomplishment or in the development of its natural consequences, have the purpose, whether as an end or a means, to render procreation impossible." (9)

Over the last decade, Catholic ethicists and health care providers have attempted to reconcile the prohibition on contraception and abortion with a growing demand within the Catholic community for a compassionate response to women who have been raped. Hardliners within the Catholic community defined the expulsion of a fertilized ovum as abortion and held that emergency contraception should be prohibited because it may prevent the implantation of a fertilized ovum. However, Catholic authorities know emergency contraception also acts to prevent fertilization, an act that is clearly contraception and not abortion. They have deemed it acceptable for a woman who has been raped to "defend" herself against the rapist by seeking to prevent his sperm and DNA from fertilizing her ovum. Therefore, Directive 36 further stated that health care providers should comply with law enforcement personnel, be compassionate with rape survivors, and provide medications to prevent pregnancy if the woman is not already pregnant.

IMPLEMENTING DIRECTIVE 36

Catholic ethicists do not agree on a standard interpretation of Directive 36. Each Catholic hospital is therefore free to implement either a liberal or a conservative policy.

Some aspects of Directive 36 are medically unsound. For example, the directive suggests a pregnancy test for each rape victim, (10) But EC must be given within 72 hours of intercourse, far too early for any test to identify a pregnancy resulting from the act of unprotected intercourse that led the woman to seek EC. A pregnancy test can only determine whether a woman was already pregnant before the assault. If so, EC will not work to terminate that pregnancy, but nor will it harm the woman or fetus. Therefore a pregnancy test administered at the time a woman seeks EC serves no medical purpose.

Furthermore, Directive 36 addresses EC only in the context of rape, implying that EC use is never acceptable under any other circumstances. What about women who need EC for reasons other than rape? If EC were widely available and used by all women who had unprotected intercourse, the need for abortion might be reduced by up to 60%. (11) In this sense, withholding EC could be contributing to higher abortion rates.

PROVISION OF EC

Our survey found that only five percent of Catholic hospitals give EC out upon request to any woman (Table 1). An additional 23% of Catholic hospital emergency rooms give EC to rape survivors, bringing the total number of Catholic hospitals that offer EC under some circumstances to 28%. Our study found that, of the 23% of Catholic hospital emergency rooms that offer EC to rape survivors, only three percent offer it to these women without restriction. The others require pregnancy tests (13%), insist that the rape be reported to the police (<1%), or were unsure of the requirements (7%). An additional six percent sometimes offer EC, at the discretion of the treating physician. Most significantly, the study showed that two-thirds of Catholic hospital emergency rooms either clearly do not provide EC at all (55%) or have unclear policies that make provision of EC unlikely (11%).

These direct quotes from respondents convey some of the more forceful or colorful denials of EC:

"Any hospital starting with 'Saint' won't help you out."

"No Catholic hospital will ever do that. They don't take rape cases."

"Honey, this is a Catholic hospital, you couldn't even come close here."

"Any doctor here absolutely won't because it's a Catholic hospital."

In some cases, however, the respondent expressed regret or apology over the restrictive Catholic policy.

COMPLIANCE WITH STATE EC REGULATIONS

Washington state law specifically requires emergency rooms to dispense EC to rape victims, yet only three of the 18 Catholic emergency rooms clearly abide by the law. Seven more dispense EC to rape survivors, but they require pregnancy tests or are unclear about pregnancy test requirements. Six do not dispense EC at all, in apparent violation of state law. As described below, however, the six Washington hospitals that did not dispense EC may have been motivated by the knowledge that women seeking EC can obtain it more easily from pharmacies in that state.

Illinois requires emergency rooms to inform rape victims about EC and give referrals on request. (See below for survey findings about referral patterns.)

California law requires both information and provision of EC, but went into effect several months after the fieldwork for this study. Of the 45 Catholic hospitals in California, fully 31 reported that they never dispense EC, even in cases of rape. Although not technically out of compliance with the law at the time of this survey, these hospitals will have to change their practice to comply with current laws.

REFERRALS

Are referrals available at the 328 Catholic emergency rooms that do not provide EC at all? Our survey found that only 47% of respondents at these hospitals named a place where EC could be obtained. A few misunderstood the legal status of EC:

"As far as I know, no ER gives them out."

"I don't know if EC is legalized yet."

In Illinois, emergency rooms are required by law to refer rape victims to a source of EC. Of the 22 Illinois respondents that said their hospitals would not provide EC in cases of rape, only six made referrals. This leaves 16 Illinois Catholic hospitals in apparent violation of state law.

The results for Washington, California and Alaska are of interest because some pharmacists in those states work under collaborative drug therapy agreements that permit the pharmacists to dispense EC to women who have not first seen a doctor. Of the four referrals in Washington State by Catholic emergency rooms, two were to other hospitals and two were to pharmacies. In the case of one of these referrals to a pharmacy, the Catholic hospital respondent said, "Those [ECs] are actually sold over the counter at any pharmacy." This statement reflects an awareness (although slight misunderstanding) of the Washington state pharmacy program. In California, 31 respondents said they would never dispense EC, and only ten of those gave referrals, none of which were to pharmacies. The single Alaskan respondent who would not dispense EC under any circumstances also would not give a referral.

As important as whether a referral was offered was whether it worked. When referrals were followed, fully 64% proved to be dead ends, leading to wrong numbers, clinics closed on weekends, or places that did not offer EC or referrals for it. About a third of referrals led to access to EC, and six percent resulted in access to EC after another one to two follow-on referrals. In Illinois, two of the six referrals were dead ends; in Washington, the two referrals to hospitals were dead ends. We also found that referrals to rape crisis hotlines, clinics, or other places were much less likely to provide access to EC than referrals to other hospitals.

Most Catholic hospitals in the US do not provide EC under any circumstances, to any women, even those who have been raped. Among those Catholic hospitals that do provide EC to rape victims, many require unnecessary hurdles such as pregnancy tests or police reports. Among those that do not provide EC at all, only half give referrals and fully two-thirds of those referrals were dead ends, not leading to prescriptions for EC. The impact of this problem could worsen for American women if the pace of Catholic hospital mergers with non-Catholic hospitals picks up, restricting reproductive health care choices.

This study also finds that Directive 36 of the Ethical and Religious Directives for Catholic Health Care Services, revised as recently as 2001, has apparently not clarified confusion about EC at Catholic hospitals. Fully 11% of hospital respondents did not know, refused to answer, or were unclear whether they provided EC, and many openly expressed ignorance or confusion.

The new laws in three states that require rape survivors to be counseled about or offered EC in all emergency rooms constitute a good start in improving the situation. Compliance is problematic, however. In Washington and Illinois, laws went into effect before our fieldwork, but in both states several hospitals may be violating state law.

The provision of emergency contraception, especially to women who have been raped, has become a standard tenet of medical care. EC is endorsed by several leading medical associations, such as the American Medical Association, the American College of Obstetricians and Gynecologists and by the United States Food and Drug Administration. (3) All health care institutions that counsel or treat women who have been raped should offer EC themselves, or should meaningfully refer women someplace where they can obtain it. Unfortunately, few Catholic hospitals fulfill this obligation.

Catholic Hospital Emergency Rooms
Willing to Provide EC, by Circumstances

                                                     Number   Percent

Never provide EC                                        328     (55%)

No response/don't know/unclear                           67     (11%)

Provide EC at the doctor's discretion                    33      (6%)

Only if not already pregnant                              3     (<1%)

Provide EC only after rape                              136     (23%)

  Rape, but no further conditions       16    (3%)

  Rape and can prove not already
  pregnant                              77   (13%)

  Rape and reported to police            3   (<1%)

  Rape, don't know about
  pregnancy test requirement            40    (7%)

Provide EC upon request                                  30      (5%)

Total                                                   597    (100%)

The authors all work for Ibis Reproductive Health, (2) Brattle Square, Cambridge, MA 02138, USA. Tel: [phone]; fax: [phone].

REFERENCES

(1) Ellertson, C., J. Koenig, J. Trussell, and J. Bull, "How many US women need emergency contraception?" Contemporary OB/GYN, 1997, 42(10): 103-128.

(2) Ellertson, C., K. Blanchard, A. Webb, A. Bigrigg, and S. Haskell, "Emergency contraception," Lancet, Oct 31, 1998, 352(9138): 1477.

(3) American Medical Association, Access to emergency contraception, "Policy of the House of Delegates," H-75, 985; American College of Obstetricians and Gynecologists, 1996, "ACOGpractice pattern number 3; Emergency oral contraception," Washington, DC, ACOG; and Food and Drug Administration, 1997, "Prescription drug products: Certain combined oral contraceptives for use as postcoital emergency contraception," Federal Register, 62(37): 8610-8612.

(4) Federal Bureau of Investigation, "Crime in the United States 2001: Uniform crime reports," US Department of Justice, US Government Printing Office, Washington, DC, online: www.fbi.gov.

(5) www.cdc.gov.

(6) American Hospital Association, Annual Survey of Hospitals 2002, American Hospital Association and Health Forum, data supplied to authors.

(7) Amey, A. and D. Bishai, "Measuring the quality of care for women who experience sexual assault with data from the National Hospital Ambulatory Medical Care Survey," Annals of Emergency Medicine, 2002, 39(6), 631-638; Clara Bell Duvall Education Fund, "Study Update: Emergency Contraception services for rape victims in Pennsylvania hospitals," www.aclupa.org, 2002; NARAL/NY Foundation, "Preventing pregnancy after rape: Does your hospital provide EC to rape survivors?" New York, NAIL, 1999; Smugger, S., B. Spina, and J. Merz, "Informed consent for emergency contraception: Variability in hospital care of rape victims," American Journal of Public Health, 2002 90(9): 1372-1376.

(8) A similar bill, the "Compassionate Care for Female Sexual Assault Survivors Act," was introduced in the US House of Representatives in April 2002 by Rep. Constance Morella (MD). It would have required all hospitals that receive federal funds to describe and provide EC to all rape victims at the hospital. Rep. Morella lost her re-election bid in November 2002, and the fate of the bill is uncertain.

(9) Pope Paul VI, Encyclical Letter, On the Regulation of Birth (Humanae Vitae); (Washington, DC: United States Catholic Conference, 1968), no. 14.

(10) L. Bucar and D. Nolan, "Emergency contraception and Catholic hospitals," Conscience, 1999, 20(1): 20-22.

(11) Grossman, R., "Emergency contraceptive pills can prevent abortion," American Journal of Public Health, 91(7): 1137.

Editorial Comment

The Ibis Reproductive Health/Catholics for a Free Choice survey demonstrates that most Catholic hospital emergency rooms are not providing proper information or access to EC. Moreover, many of these hospitals claim that they either cannot provide EC to women who have been raped or can only do so under very limited and restricted circumstances. They seek exemptions from laws requiring the provision of or referral for EC, claiming violations of conscience or religious freedom.

Hospitals are community assets as reflected by the legal and tax status they enjoy. Health care is a public trust, and moral decision-making is the right of individuals. A Catholic hospital that does not put the conscience and religious freedom of individuals first is not living up to the Directives' claim that it provides "compassionate and understanding care ... to a person who is the victim of sexual assault." If Catholic health care providers do not understand this, then it is essential that we pass laws that serve to protect the religious freedom, conscience and health of women.

Readers interested in the full report, Second Chance Denied: Emergency Contraception in Catholic Hospital Emergency Rooms, can find it at www.ibisreproductivehealth.org and www.catholicsforchoice.org. Bound reprints costing $10.00 can be ordered through those websites and from Ibis Reproductive Health: [phone], or Catholics for a Free Choice: [phone].