When Hoag Hospital announced this spring it would no longer provide elective abortions, officials at the esteemed Orange County medical center said the decision was made because of low demand.
But records and interviews show the decision was closely tied to the hospital's new partnership with a Catholic healthcare provider.
Hoag Hospital officials told The Times this week they wanted the deal to go through and knew elective abortions were a "sensitive issue" for St. Joseph Health System, which has a "statement of common values" that prohibits them.
Richard Afable, a top executive at St. Joseph Health who runs the joint health network, said that his organization made it clear to Hoag that the abortion ban was "sacrosanct" and "required of ourselves and anyone we would work with."
So on May 1, Hoag Hospital stopped providing elective abortions and promised to refer patients elsewhere.
The California attorney general's office, which approved the alliance in February, is now investigating whether Hoag Hospital is doing enough to ensure that there are accessible alternatives for elective abortions, especially for low-income women. The office is also looking into whether Hoag officials were accurate in reporting that the hospital does fewer than 100 elective abortions each year. [Updated at 7:17 p.m.: A Hoag spokeswoman said the hospital is fully cooperating with that probe.]
Hoag's move -- which sparked fierce criticism and concern among doctors and women's health advocates -- has been echoed around the nation with growing numbers of mergers and partnerships between Catholic and non-Catholic hospitals. In the rapidly changing era of health reform, hospitals are increasingly joining forces to cut costs and expand their reach. When mergers involve Catholic institutions, which already serve one in six patients in the U.S., that can result in restrictions on abortions, contraception and sterilization -- and debates about the clash between religious directives and reproductive health.
"Catholic systems are growing .. that can really affect many aspects of care," said Debra Stulberg, assistant professor at the University of Chicago who studies Catholic healthcare. "Women are having fewer and fewer places they can go for care, they are having to travel further and further."
Hoag Memorial Hospital Presbyterian and St. Joseph Health System, both nonprofit companies, announced their plans in August, saying the partnership would lead to broader, more integrated healthcare services across the county. St. Joseph Health System operates five hospitals in Southern California and Hoag has two hospitals and several clinics.
A consultant's report about the alliance said that Hoag would not be successful in the long term under health reform unless it was part of a larger healthcare system. The two institutions did not merge and retained separate leadership and faith-based identities, though together they form the Covenant Health Network.
Physicians said they raised concerns last fall about the effect of Hoag Hospital partnering with a Catholic institution but said they were told that hospital care policies wouldn't change.
"They flat-out said it's not going to affect you at all," said Beverly Sansone, an ob/gyn who treats patients at the hospital. She and seven other Hoag-affiliated doctors recently penned a public letter saying they were "shocked and dismayed" about the ban and that forcing women to go elsewhere for care is "bad medicine."
Documents and interviews show that Hoag administrators knew about the elective abortion ban late last year, though they didn't announce it until March. A consultant wrote in December that Hoag wouldn't be bound by Catholic Church directives on reproductive healthcare but would be subject to St. Joseph's "statement of common values" prohibiting elective abortions. By February, the abortion ban had become a condition of the partnership.
Hoag's chief executive, Robert Braithwaite, said the hospital board was aware of St. Joseph's views on reproductive health so decided to conduct a thorough review. The board then determined that "the continuation of elective abortions at Hoag was not the optimal solution to maintain the highest-quality family planning services to women in our community," he said. Hoag officials said they are confident women have other, high-quality options, including Planned Parenthood and UC Irvine.
Hoag decided, however, to continue other care not typically found in Catholic hospitals, including sterilization and fertility treatments. The hospital has also pledged to continue providing emergency contraception following rape or sexual assault and managing pregnancy complications.
Jon Dunn, chief executive of Planned Parenthood of Orange and San Bernardino Counties, said his organization plans to work with Hoag to ensure the patients get the care they need. But Dunn said he believed Hoag's decision was part of a "troubling trend" of the Catholic Church using religion to restrict medical care.
Knowing the Catholic Church's directives on care, doctors fear other services at Hoag could be limited in the future. The attorney general's approval of partnership said that Hoag Hospital must continue all other forms of reproductive health for 10 years. But Sansone, the ob/gyn, said a decade will pass in the "blink of an eye."
Doctors may be right to worry because Catholic hospitals don't typically stop after limiting abortions, said Stulberg of the University of Chicago. Even if a hospital retains its own religious or secular identity, its leaders may make voluntary changes to maintain a friendly business relationship with a Catholic institution.
Sheila Reynertson, advocacy coordinator for the New York City-based nonprofit MergerWatch, said she has seen such changes around the country. The Hoag decision was especially problematic, she said, because administrators appeared to be less than candid about the reasons for the ban. Restricting reproductive care can put both patients and medical providers in a difficult position, said Wayne Shields, chief executive of the Assn. of Reproductive Health Professionals. While women can usually find places to terminate their pregnancies in urban centers such as Orange County, they find it harder in more far-flung areas. "As we see more Catholic hospital systems taking control, access is reduced," he said.
Allyson Brooks, executive medical director for Hoag's Women's Health Institute, said the hospital has "no intention, plans or ideas" to stop providing the full scope of women's healthcare. The vast majority of abortions do not need to occur in a hospital, and women with miscarriages or pregnancy problems can still be treated at Hoag, she said.
"Women that have complications that warrant them being taken care of in a hospital setting with their physician will continue to be taken care in the same way they have been for 60 years," she said. "There is no oversight by our affiliates."