My column below was published 8/2/2011 as “Hospital Merger is a Double-Edged Sword for Indigent Women,” in The Forum section of the Courier-Journal.  I wasn’t going to re-post it here, but I after hearing this story on NPR’s All Thing’s considered today about birth control and religion in Pakistan, I thought it was worth repeating.  The observations made in the story sound frighteningly familiar.

For indigent women, University of Louisville’s merger with Jewish Hospital and Catholic Healthcare Initiatives is a double-edged sword.  The Ethical and Religious Directives for Catholic Health Care Services acknowledge health care’s precarious state in our country and mandate that health care providers at Catholic institutions commit to treating the least of these in our society as equals to people who can afford the best health care.

In that respect, the merger is a gift to all women, especially women who are among the marginalized groups a Catholic health care institution is distinct in serving, including the poor, the uninsured, single parents, racial minorities and immigrants and refugees.  But when it comes to the reproductive care of these women, the same directives that cherish them as people may not allow doctors to give them the treatment they need.  Instead, they may aggravate an impoverished woman’s circumstances.

A dear friend of mine has worked for the past three years as an obstetrician and gynecologist at hospitals inBostonandChicagothat serve indigent populations and are under Catholic health care directives.  I told her about the impending merger here and asked for the worst-case scenarios regarding women’s reproductive care.

She described seeing young mothers who just had a baby return for their six-week follow-up visit pregnant.  Women have babies 11 months apart.  That doesn’t give a woman’s body much chance to recover but does leave her or her family with two infants to take care of.  Poor women who had trouble feeding four kids had more.  At one hospital, the directives did allow doctors to perform tubal ligation on women who already had a certain number of children.  My friend remembers the number being something around six.

Doctors who knew that the best thing for a patient would be to give her a shot of Depo-Provera before she leaves the hospital couldn’t prescribe it.  An injection that remains effective for three months is probably ideal for someone who is too young for tubal ligation, is as irresponsible as teens tend to be and could possibly afford birth control pills at Wal-Mart for $9 a month but needs something she doesn’t have to remember every day.  For an uninsured, under-employed married couple that wants more children some day, when they’re no longer struggling to provide for the ones they have, Depo-Provera would be more effective than the unspecified “natural means” of “contraceptive interventions” the Catholic directives approve.

Then there’s women who have a chronic disease that makes pregnancy dangerous or more difficult, or who are taking medications you shouldn’t take if you are nursing, pregnant or may become pregnant.  Doctors can prescribe medication that poses a serious threat to the baby’s health or life, but they can’t prescribe contraceptives or perform tubal ligation.

University of Louisville has talked about providing tubal ligation and contraceptive services at the medical school or building a hospital within the hospital specifically for the reproductive care that the Catholic directives ban.  But if those locations are not under Catholic Health Initiatives, do they have the same obligation to provide for the poor and the uninsured?  No matter how much the staff wants to care for the vulnerable, can the additional hospital afford to?  Forever?

Let’s say the extra facilities can afford this.  Certainly, most indigent women could walk to another building in the University of Louisville Health Caresystem to get these services.  But when you’re beaten down from everything in life besides your illness, or you’ve just experienced a traumatic event, or you simply are not used to sticking up for yourself or taking care of your health, what would normally be a minor inconvenience can be a major barrier to receiving quality health care.

Imagine a teenage girl who speaks little English having her first child and being told, “Yes, you’re at University of Louisville Hospital, but you have to go to the University of Louisville School of Medicine down the street to get that injection.”

And though it affects women irrespective of socio-economic status, I keep picturing a sexual assault victim having to choose whether to stay in the hospital a few days and treat injuries from a violent attack properly, or leave so she can get emergency contraception somewhere else and then come back.  I wouldn’t want to return to a hospital that forced me to do that.

Unfortunately, the people the merger affects the most don’t have a PPO that allows them to shop around.  They will have a facility that cares deeply for their body, mind and soul and that values them simply because they exist.  That’s a great thing in health care.  But as with anything else in our health care system, it comes at a cost to the most marginalized.