The Contraception Controversy: A Comprehensive Reply (6 of 7)

The Obama Administration’s recently announced policy to require insurers to cover contraception as women’s preventive health care has prompted many over-heated op-eds, editorials on both sides and even a thoroughly one-sided Congressional hearing. The controversy is unlikely to end anytime soon: pending federal legislation and proposed amendments would massively enlarge the scope of insurers’ and business owners’ ability to restrict any type of insurance benefit on either “moral” or “religious” grounds, undermining the very purpose of insurance.

Below, we take a closer look at the arguments by opponents of the contraception requirement, unpack the legal issues and public health debate, and respond to many erroneous assertions.

Full Introduction

1) Religious liberty and the right of an individual to live according to his or her own religious conscience are supported, not threatened, by this policy.

2) Both the original policy and the accommodation are legally and constitutionally sound.

3) The Administration’s policy accommodation fairly balances the interests of employers and employees and is based on the economic realities of the insurance marketplace.

4) Birth control coverage is a mainstream and commonsense aspect of preventive care for women.

5) Emergency contraception is essential to women’s health and is not an “abortion drug.”

6) Sterilization is a common form of birth control. Denying access, especially when it is medically recommended, can have devastating consequences.

Contrary to assertions by opponents, sterilization is a common form of birth control and one that is recommended for certain women’s health. American women rely increasingly on sterilization as a form of contraception as they get older. In 2002, 50% of women 40 and older relied on this method.^[i] Sterilization is more commonly used by women with more children, and those with lower education and income.^[ii] Post-partum sterilizations are often recommended for women who have had three or more c-sections because they face increased risk of significant pregnancy complications with a subsequent c-section delivery.

When women cannot access sterilization, the consequences can be severe. Research by Lori Freedman and Debra Stulberg reveals that the primary disadvantage of working in a Catholic hospital cited by physicians was the inability to perform sterilizations, particularly following a c-section delivery (which eliminates the need for a second procedure). This physician sentiment was borne out by fact-finding research conducted by the Center for Reproductive Rights in three communities in which previously secular hospitals came under Catholic control.

One doctor described in vivid detail the impact of the denial of sterilization services required by strict adherence to Catholic doctrine:

There are only so many c-sections a woman should have. With every one the next pregnancy is markedly compromised. [T]here’s a higher risk the placenta can implant on the uterine scar … you can’t get the placenta out, there’s morbid hemorrhage [she demonstrates by turning on the faucet until the water runs vigorously]. …It’s absolutely unconscionable … The Pope, the Cardinal, the Board is not going to be there, not going to be here when she is hemorrhaging, bloody, you can’t see, it’s horrible, the uterus is cut, she needs a massive transfusion. Six months later she still looks awful, like death warmed over, she can’t take care of the little ones she has. ^[iii]

For women with difficulty accessing reversible contraceptive methods, sometimes sterilization is the only viable option, removing it as an option can literally be fatal. All of the physicians we interviews told stories of women under their care who had been unable to obtain sterilizations, and who subsequently became pregnant when they did not want to be, most tragically, one woman who had wanted the procedure and had six children had died in childbirth.

As noted above, for many women a post-partum sterilization is recommended when additional pregnancies are not only undesired but would threaten the woman’s health. Refusing to perform a sterilization following childbirth in such circumstances means denying to a patient wanted and needed medical care, and will also mean that the woman must subject herself to a second, unnecessary surgical procedure at another institution. This means another round of anesthesia and the risk of infection and complications that normally accompany surgery. Moreover, this burden is being placed upon a woman who has just given birth and is not only recovering but has the responsibilities of caring for a newborn.

In addition to the personal burden and health consequences, a second surgery at a separate facility means additional costs. The refusal of religious health care institutions to provide sterilization as part of delivery not only forces upon women needless additional medical intervention, it drives up healthcare costs that either the woman herself or her insurance plan must cover.

For women for whom an immediate post-partum sterilization is medically indicated, refusal to allow this procedure to be performed based on religious directives to which a hospital subscribes amounts to an unethical denial of care. The American College of Obstetricians and Gynecologists, while acknowledging the legitimate place for individual provider conscience in medicine, warns that “conscience also may conflict with professional and ethical standards and result in inefficiency, adverse outcomes, violation of patients’ rights, and erosion of trust if, for example, one’s conscience limits the information or care provided to a patient.”

The College notes that refusal is particularly common in the field of reproductive health care: “[i]t is not uncommon for conscientious refusals to result in imposition of religious or moral beliefs on a patient who may not share these beliefs, which may undermine respect for patient autonomy. Women’s informed requests for contraception or sterilization, for example, are an important expression of autonomous choice regarding reproductive decision making. Refusals to dispense contraception may constitute a failure to respect women’s capacity to decide for themselves whether and under what circumstances to become pregnant.”

Addressing sterilization specifically, the ACOG committee opinion states: “Although conscientious refusals stem in part from the commitment to ‘first, do no harm,’ their result can be just the opposite. For example, religiously based refusals to perform tubal sterilization at the time of cesarean delivery can place a woman in harm’s way — either by putting her at risk for an undesired or unsafe pregnancy or by necessitating an additional, separate sterilization procedure with its attendant and additional risks.”

7) Conclusion

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