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We never had this conversation," the nurse manager said. She glared at me and asked if I was giving birth control counseling to the women. I nodded. It was one of the necessary items to finish clinical rotation as a nursing student. My clinical rotation supervisor said we could cousel women on birth control, but "not to get caught." I thought she was joking. In Philly and around the nation, Catholic, Adventist and some Baptist hospitals broadly restrict much reproductive health care. Services that are banned or limited include not only abortion and contraceptive services, but prenatal testing and genetic screening and counseling. Often banned, according to the American Public Health Association, are: € Birth control to help women avoid pregnancy € Voluntary sterilization, such as tubal ligation € HIV prevention, which includes counseling the use of a condom. An industry survey reports that religious organizations operated 11 of the 20 largest health systems in the U.S. in 1999. While religious and secular health care merge in the face of competition, access to reproductive health care shrivels. Alis Kotler-Panzera, graduate Nursing student in the Health Care of Women Nurse Practitioner program at Penn, recalls a similar experience at St. Peter's Hospital in New Brunswick, N.J. She cared for a client who had just delivered her fourth or fifth child and had no health insurance. "She begged, OCan you please just tell me anything about contraception?'" Kotler-Panzera said. "The nurse and doctor literally dragged me out of the room. I cried afterwards." Recent findings underscore the paucity of options after a restrictive religious health care provider merges with a secular hospital. Emergency contraception policies for rape victims rarely survive. In 1999, 82 percent of the 589 Catholic hospitals in the U.S. reported no provision for emergency contraception, even in the case of rape or incest. Thirty-one percent of Catholic hospitals admit that they would not provide a referral to another facility in such a situation. However, a rape survivor has less than 72 hours to act to protect herself from pregnancy. Although recommended by the American College of Obstetricians and Gynecologists as standard care for rape victims, emergency contraception is not an option in most religion-restricted systems unless care givers, like my nurse manager, look the other way. In Pennsylvania, an overview of ERs at 125 hospitals shows that only 6 percent of Catholic hospitals consistently offer emergency contraception to rape survivors. Unregulated mergers threaten other forms of reproductive health. A Catholic health care system in California, for instance, prohibited one mother of nine from having her tubes tied. But when reality collides with wrong-headed regulations, the results can be life-threatening. A New Hampshire hospital dumped a woman when her water broke at 14 weeks. Her hospital placed the prematurely laboring woman in a cab and rushed her to a non-Catholic hospital out of town. The laboring woman belonged to a Medicaid HMO, giving the hospital the chance to deny her treatment under protection from Congress. In 1997, Congress voted to allow Medicaid health care plans to refuse to pay for coverage of a referral if it objects "to the provision of such a service on moral or religious grounds." Enrollees in Catholic-managed HMOs must find and pay for other providers who will accept Medicaid. The sweetener to managed care in this deal is reduced cost, resulting in a greater share of the Medicaid dollar in the pocket of the Catholic HMO. Legislation introduced in New York and California to protect patients' rights would require mergers between health care providers to undergo state approval, which would be contingent upon continued patient access to reproductive health care services. But Congress must also close the loophole allowing hospital systems to deny care on so-called "religious or moral grounds." Is it moral to place a miscarrying woman into a taxi with the risk that she could bleed to death to send her to a different hospital? No. It's a smoke screen that allows religion-controlled hospitals to deny services to female Medicaid recipients. When health care meets religion, human decency should prevail.

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