Abortion remains legal in California, but there have been barriers to access since well before the Supreme Court overturned Roe vs. Wade. In Mendocino and Humboldt Counties, religious hospitals refuse what they term elective abortions. And the Hyde Amendment, which prohibits the use of federal funds for abortion, means that Medicaid recipients and patients at federally funded clinics like VA and many community health centers have to rely on secondary insurance or other providers for the service. But the costs of travel and taking time off work can be prohibitive for people who don’t have a lot of discretionary income or reliable transportation.
But the pandemic has legitimized telehealth, and many doctors no longer require ultrasounds to prescribe mifepristone and misoprostol, the two medications that are used to induce an abortion in the first trimester of pregnancy. And organizations that step in to cover patients’ expenses are flush with volunteers.
Gloria Martinez, the Senior Director of Operations at Planned Parenthood Northern California, which includes Mendocino and Humboldt Counties, said her affiliate calls on an organization called Access Reproductive Justice about once a week to give patients a ride or airfare, or even to help cover the cost of the medication or the procedure. Abortion comprises about 3% of the services that Planned Parenthood provides across Northern California, with approximately 3,000 abortions per year. Patients at the Planned Parenthood clinic in Ukiah can get a two-drug medication abortion up to ten weeks. The nearest providers for a surgical abortion are in Santa Rosa, at either the Planned Parenthood clinic, which offers the procedure through 16 weeks, or the Women’s Health Specialist of California clinic, which provides it through 18 weeks.
The Planned Parenthood clinic in Eureka offers medication as well as an in-clinic surgical procedure up to 13 weeks and six days. Martinez said most patients can get an appointment within a week, sometimes sooner, and that the centers have been increasing their hours and staffing. The cost for an abortion at Planned Parenthood is on a sliding scale for patients who do not have insurance available.
But scheduling an appointment for a gestationally appropriate abortion can be difficult for patients who don’t know how far along they are in their pregnancy. Many women who are very young or approaching menopause have irregular periods, which makes it difficult to calculate when they became pregnant. There is also a variety of medical conditions, from excessive stress to endometriosis, that can cause unpredictable menstrual cycles.
The access hardship is compounded for those who don’t have cars or smart phones. Martinez recalled that recently, a volunteer from Access Reproductive Justice gave a patient a ride from rural Mendocino County to the clinic in San Francisco, which offers abortions up to 17 weeks and six days. (Access Reproductive Justice is not taking new volunteers at this time, due to overwhelming interest.)
But religious hospitals are a significant feature of the healthcare landscape of rural California. In Mendocino County, Adventist Health manages all three hospitals, while in Humboldt County, there is a Catholic Providence Hospital in Fortuna and a Providence-Saint Joseph’s hospital in Eureka. The Mad River Community Hospital in Arcata is secular. The small, critical access Jerold Phelps Community Hospital in Garberville is mostly funded with federal money, so it is subject to the Hyde Amendment. The pharmacy, which, like the hospital, is part of the Southern Humboldt Community Healthcare District, fills prescriptions for misoprostol, which has other medical uses besides abortion. Plan B, or the “morning after” birth control pill, is also available.
In 2019, when the Mendocino Coast Healthcare District Board was looking for a larger hospital to take over the management of its small hospital in Fort Bragg, the ACLU sent the board a letter cautioning it not to partner with a religious hospital, writing that “Religiously affiliated health care entities impose significant restrictions on the care they permit in their facilities, leading to discriminatory denials of care.” The letter cited abortion and transgender care specifically, and urged the board to “fulfill your legal obligation to ensure access to abortion care at MCDH. We also urge you to prioritize partnership with an entity that will not restrict care at MCDH based on religious doctrine.”
Medication abortions are among the services offered at an outpatient clinic in Fort Bragg that is now owned by Adventist. That’s due to the efforts of a reproductive access group that worked to make sure abortion care was in place before Adventist took over. “It was quite a difficult process, just because there was a lot of obstruction,” said Dawn Hofberg, a retired Physician Assistant who is a long-time member of the group. “The medical abortions now are being done through the Adventist outpatient clinic through the help of the referral services that are happening through Mendocino Coast Clinic’s Blue Door,” and the Mendocino Coast Women’s Health Clinic. The MCC is federally funded, which means it cannot offer abortions.
Prior to the Adventist takeover, said Hofberg, “It seemed like there was an agreement that whatever services were currently being provided in the community would continue to be provided by Adventist, should they take over. Of course, the biggest thing on the table was OB-GYN, which was eliminated…we could see that OB-GYN was going to be taken away, but we decided to form this group to make sure that some kind of abortion services on the coast would continue. We would very much like for both medical abortion and surgical be options for our community, but at this point, all surgical abortions are done in Ukiah or Santa Rosa, at Planned Parenthood or other private clinics.”
The Adventist clinic is not listed on a much-touted app called abortionfinder.org, where users can type in their zip code and the date of their last period to find a clinic that offers them the type of abortion they need. That may be because the facility, which prescribes abortion medication once or twice a month in addition to a myriad of other services, is not a dedicated abortion clinic.
Adventist would not discuss its abortion policies with us, but in 2019, during a proposed merger with another hospital in Delano, Adventist Health told the Attorney General that “Medical abortions are performed in Adventist Health facilities.” However, the document continues, “Abortions are not performed on demand.” Adventist wrote that its physicians can provide tubal ligations and hysterectomies, “based on their clinical judgment and mutual decision making with their patients.” In non-life threatening situations where a pregnant woman requests an abortion, the hospital convenes an ethics committee to make a recommendation about what to do. Adventist “does not support on demand abortions (an elective abortion without medical justification).” Its answer to a question about whether or not it provides contraception was uninformative, saying that “It is the prerogative of the Adventist Health physician and patients to make decisions and treatment modalities on contraceptive services immediately postpartum;” and that “Adventist does not interfere in the physician’s relationship with their patients. This includes discussion of Plan B and IUDs. There is no exception.”
The policies are entirely legal, even before the downfall of Roe. Lori Freedman is a sociologist and Associate Professor at UCSF, and a researcher with the Bixby Center for Global Reproductive Health and a group called Advancing New standards in Reproductive Health, both out of UCSF. “We have a lot of conscience protections in the United States,” she said. “Some scholars have called it conscience creep. Initially, when abortion was legalized in 1973, there was the first conscience clause, the Church Amendment, that said no one would be forced to provide abortions. But importantly, that got broadened to cover institutions. Once it was determined that institutions have conscience rights, that paved the way for all Catholic hospitals to have a doctrine” which overrode the consciences of the people who work within the hospitals. At Catholic hospitals, a set of Ethical and Religious Directives (ERDs) forbids contraception, sterilization, or abortions, even in cases where the pregnancy is causing severe health complications. The 44th ERD states that, “While there are many acts of varying moral gravity that can be identified as intrinsically evil, in the context of contemporary health care the most pressing concerns are currently abortion, euthanasia, assisted suicide, and direct sterilization.”
Freedman is the lead author of a 2008 article called “When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals,” which cited the experience of doctors who said that hospital ethic committees often deny uterine evacuation to patients suffering miscarriages, “if fetal tones are present and the pregnant woman is not yet ill, in effect delaying care until fetal heart tones cease, the pregnant woman becomes ill, or the patient is transported to a non-Catholic-owned facility for the procedure.” Doctors reported instances where patients were denied the “uterine evacuation,” essentially an abortion or hastened miscarriage, even if they were hemorrhaging or already suffering from an infection.
A more recent study is a 2018 Columbia Law School report called “Bearing Faith: the Limits of Catholic Health Care for Women of Color” found that “a significant and growing proportion of the U.S. population” receives healthcare from Catholic hospitals, which “has had a disproportionate effect on the sexual and reproductive health care available to women of color in many communities.” The report found that one in six hospital beds in the entire country are in a hospital governed by the Catholic rules, and that, in 19 out of 34 states studied, including California, “Women of color’s disproportionate reliance on Catholic hospitals…increases their exposure to restrictions that place ideology over best medical practices.” In some communities, more than 40% of the hospital beds are at a Catholic hospital.
At the Mad River Community Hospital in Arcata, patients receive surgical or medication abortions with no questions asked. “We support women’s rights,” said hospital CEO David Neal, who is also a nurse. The hospital does not operate an abortion clinic, but Neal said doctors are able to use the facility about once a month for surgical abortion procedures. While the hospital is not a dispensing pharmacy, it does have Plan B (the “morning after pill,”) available for utilization by its emergency room physicians. About 40 babies a month are born at Mad River, and the hospital does provide tubal ligations to qualifying patients, some of whom have been denied the procedure after delivering babies at Providence Saint Joseph’s. Mad River also provides hysterectomies, sometimes for patients who are in the process of female-to-male gender reassignment.
Freedman said there is a lot of good protective abortion legislation going forward in California, but, “I’m not able to think of a way that that would actually affect what happens inside religious hospitals because they’re so incredibly protected.” On the federal level, she would like to see the repeal of the Weldon Amendment, which withholds U.S. Health and Human Services funding from public entities that discriminate against institutions, insurance plans, and healthcare providers who refuse to “provide, pay for, provide coverage of, or refer for abortions.”
Freedman reflected that, “The Weldon is insidious, because it prevents us from making policy changes that will impact institutions that are institutionally constraining care. But I do think the more people know about it, I think it’s important,” so that patients and healthcare providers can make choices about where to seek care — if those choices are even available to them. “But these are all individual level solutions, and what we really need is a structural one, so it’s hard,” she conceded. And she pointed out that the Supreme Court remains relevant, even in California, where its decision to overturn Roe led to a slate of supportive legislation and budget measures.
“One of the key points in this time period is that the Supreme Court is so pro-religious rights that any court case that would attempt to change the status quo could result in really worse law than already exists.”