When Sarah*, a Melbourne mother, was pregnant with her second child, her GP gave her a surprising warning: if she had any serious complications, concerns about the viability of the pregnancy or believed she might be miscarrying, she should go to the Royal Women’s hospital rather than the Mercy Hospital for Women, where she was planning to deliver the baby.
The reason, the GP told her, was that the Mercy – a public hospital in Melbourne’s north-east – would not assist in terminating a pregnancy due to its Catholic affiliation.
“Further along the pregnancy, when I was part of the midwife program, I asked one of the Mercy midwives and she confirmed it was against the Mercy’s policy,” Sarah says.
“I was kind of shocked. It’s a public hospital and we’re a secular country, so it didn’t make sense.” The midwife “agreed it was a silly policy, but their hands were tied”. Fortunately, Sarah delivered her baby in March without complications.
Like a number of publicly funded Catholic hospitals around Australia, the Mercy’s religious affiliation limits the scope of reproductive services it provides. “Sexual assault does not get seen at the Mercy specifically because they can’t provide morning-after contraception,” claims a senior gynaecologist who works in Melbourne and asked to remain anonymous.
Women who ask for a tubal ligation – a permanent contraceptive procedure that involves surgically blocking or clipping the fallopian tubes – after delivering via caesarean section will also usually have their request denied. “The trainees know that it’s a Catholic hospital and that you can’t tie tubes,” the gynaecologist says. “That means that some of those women are being forced to get a second anaesthetic because they’re having their tubes tied six months later at the [neighbouring] Austin hospital.”
Prior to the Covid pandemic, doctors worked around the religious constraints by walking women who wanted Implanon contraceptive implants or intrauterine devices (IUDs) down the corridor to have the procedures performed at the Austin. “It’s not a good feeling,” says a doctor who works as an abortion provider in Melbourne. “Every time you have to use a loophole, it means that you’re still creating stigma for the patient.” Doctors say since the pandemic, some contraception is now being administered onsite at the Mercy.
A spokesperson for Mercy Health said: “Patients present to Mercy with any range of issues and situations, including sexual assault. Clinicians use clinical judgment, with reference to the Catholic Code of Ethics and established partnership arrangements with other public health services to ensure patients receive the comprehensive care they need.”
Following years of concerns about access to women’s health services, a Senate inquiry into reproductive healthcare access tabled a report of recommendations in May. But doctors and family planning advocates say the inquiry has failed to tackle one of the most galling issues: publicly funded hospitals denying women basic reproductive healthcare.
‘It’s really stigmatising’
The Mercy is one of 15 Catholic public hospitals in Australia, at least five of which provide specialist maternity or gynaecology care. Despite public funding, multiple hospitals are bound by Catholic Health Australia’s code of ethics, which prohibits birth control, IVF and abortions, even after rape.
Women who give birth in the public system are typically assigned to a health service according to their residential address, and this may be a Catholic hospital if they live in that catchment area. Many hospitals will not treat patients who fall out of the catchment zone, creating what some family planning workers describe as a postcode lottery for access to services.
At Brisbane’s Mater hospital, which multiple experts described to Guardian Australia as the most advanced obstetric hospital in Queensland, doctors are unable to prescribe the pill or insert Mirena IUDs without obfuscating or fabricating their purpose.
“The Mater will prescribe contraception for things like acne or heavy menstrual bleeding,” says a doctor who has worked as an obstetrics registrar there. Contraception itself is not a permissible reason.
“I’ve provided referrals to [abortion and contraception provider MSI Australia] for medical termination … It’s at the discretion of the doctor. The speech I give is that this is a Catholic hospital and we don’t do that, but here are some services that do.”
Another doctor, who trained in obstetrics at the Mater, recalls being told by a senior colleague when she asked about prescribing a patient an IUD: “You’ll need to change or modify the reason for why you would give her a Mirena.
“He did say we’re not allowed to give the Mirena as a contraceptive. I just remember thinking that was really terrible.
“They didn’t offer tubal ligation basically for anyone. It’s a public hospital and any other hospital would do that.”
Daile Kelleher, the chief executive of Children by Choice, describes the lack of reproductive services at the Mater as “the elephant in the room” because of its status as one of the largest obstetrics and training hospitals in Queensland. “Everybody knows it’s an issue and no one wants to do anything about it,” she says.
Children by Choice offers Queensland-wide counselling services for pregnancy decision-making. Its counsellors dread hearing that someone lives south of the Brisbane River in the Mater’s catchment area. “[The counsellors] have supported people … to literally put someone else’s address on their records so they can access something north of the river,” Kelleher says.
“We’ve heard of people being turned away from the Mater … with suicidality and attempted self-abortion. If you look at the legislation in Queensland, even if there is conscientious objection, you can’t turn someone away in an emergency.
“We have people who have really wanted pregnancies who get exceptional care from the Mater, who have a foetal anomaly or fatal foetal diagnosis, and [then] they’re basically told, ‘Sorry, that’s where our care ends and we can’t continue to support you if you’re going to be terminating this pregnancy.’
“It’s really stigmatising, it’s really judgmental and it creates shame. It puts them out of the public system and into the private system … to access termination of pregnancy.”
It’s a reality gynaecologist Dr Catriona Melville, the MSI Australia deputy medical director, found “shocking” when she first moved from Scotland to Australia. “I realised fairly quickly that there are religious hospitals … and that generally most of them will not provide the full gamut of sexual and reproductive health services. So contraception, abortion being the main ones, but obviously contraception for men as well, such as vasectomy.
“It was an alien concept to me to have religion involved in healthcare, which should be an evidence-based public provision. It was a cultural shock for me as an internationally trained doctor, landing in Queensland as a reproductive health specialist.”
She adds: “We have been contacted by medical staff from public hospitals who can’t get advanced training in contraception.” MSI has accommodated some of these doctors for observerships in its clinics.
Melville says there are a variety of reasons people choose to work in large hospitals “even if they don’t agree with the religious principles”.
“Doctors do understand when they sign up that this is the framework they will be working under, which is extremely limiting for them, but obviously the person that suffers most is the patient,” she says.
“Individual clinicians treat people well, but their hands are tied.”
In Queensland, there are additional concerns about reproductive health access because the Mater is contracted to run a flying obstetrics and gynaecology service in regional areas. It is also building a 174-bed public hospital in Springfield, south-west of Brisbane, which includes maternity services and to which Annastacia Palaszczuk’s government has already pledged an initial $177m in funding.
The story is similar in other jurisdictions. In Perth, the St John of God Midland public hospital provides maternity care, “but of course people who require contraception before going home with their babies have to go elsewhere, which creates barriers to access”, says Dr Alison Creagh, a sexual and reproductive health specialist in Western Australia.
“As you can imagine, having a new child makes it difficult to see another health service to get your contraception sorted,” she says. “I’m really shocked that it was allowed to happen in the first place and I think that should be rectified as soon as that’s possible.
“It’s an essential service, both to people wanting to access the service but also for the doctors who are wanting to train in comprehensive either gynaecology or primary care.”
In the ACT, an inquiry into abortion services in April was critical of the Catholic-run Calvary public hospital’s refusal to provide “full reproductive health services in accordance with human rights”. One woman who had experienced an incomplete miscarriage was refused a dilation and curettage at Calvary because the procedure is also used for abortions, the inquiry heard. The inquiry report was updated in June to clarify that the woman was advised by her obstetrician that Calvary would not provide a D&C because her condition was not an emergency. The update reflected that the evidence demonstrated community unease about what services Calvary may or may not provide, which would be resolved if the hospital provided “full reproductive health care”. The ACT government has since acquired the hospital in a forced takeover.
A spokesperson for Catholic Health Australia said that “CHA members are dedicated to making sure every woman entering its hospitals receives the care she needs”.
“Our member hospitals respect a woman’s right to make medical decisions in line with her own conscience. We understand these can be difficult decisions, involving difficult circumstances and time constraints, and pastoral care and counselling are available.
“If a clinician at a CHA member hospital believes the continuation of a pregnancy poses a serious threat to the health or life of the mother, they will carry out the necessary interventions, consistent with the patient’s wishes and consent.”
“If a clinician in a CHA member hospital makes the clinical judgment that the use of birth control is necessary for medical reasons, then the code of ethical standards supports them in that decision.”
The Mater and St John of God Midland referred Guardian Australia to the statement made by CHA.
Unlikely to change
In July the prime minister, Anthony Albanese, indicated the federal government was unlikely to go as far as requiring public hospitals to provide abortions in return for their funding.
That seems unlikely to change, given the Senate inquiry into reproductive healthcare access recommended in May that publicly funded hospitals only “be equipped” to provide surgical pregnancy terminations. The inquiry’s chair, the Greens senator Larissa Waters, says this is a problem.
“They stopped short of making it a requirement for all hospitals receiving public funding, or requiring the commonwealth to fund the local affordable alternative service,” she says. “Without fully funded referral pathways, people who cannot access a termination through their local hospital are at a significant disadvantage. And this will be felt even more acutely by people in rural and regional Australia and those without a Medicare card.
“Abortion care is basic healthcare and the Greens believe that means it should be available at any public hospital, with no out-of-pocket costs. However, patients don’t care where they have to go to get an abortion, whether it’s a hospital or a local private alternative, as long as it’s free of charge, local and accessible.
“Given Labor has ruled out returning to its 2019 position of mandating hospitals provide abortion care as a condition of receiving taxpayer funding, we want to see a commitment to funding the ‘timely, affordable and local pathways’ to ensure people aren’t falling through the cracks.”
Monash University reproductive care and abortion researcher Dr Shelly Makleff says the wording of the recommendation is “disappointing”.
“I believe that in a taxpayer model, hospitals that receive taxpayer money should be obligated to provide care to anyone who walks in – and that means that they shouldn’t be able to deny abortion care, tubal ligation, et cetera.”
One submission to the inquiry, from obstetrician Dr Wendy Hughes, criticised Catholic hospitals for refusing “termination of pregnancy for any reason, including lethal foetal anomalies, despite taking taxpayer funds to set up maternofoetal units to diagnose these for the kudos but then ‘outsourcing’ the resultant terminations to secular hospitals”.
Hughes also expressed concern about terminations being refused in urgent situations “where mothers’ lives are at stake and the outlook for the foetus is extremely dismal, such as midtrimester rupture of membranes with oligohydramnios, which is very high risk for developing chorioamnionitis and a cogent reason for termination to protect a mother’s life”.
Kelleher, of Children by Choice, says federal and state governments “need to tie public funding … to the delivery of the full suite of pregnancy outcomes”.
“All pregnancies have an outcome, whether that be miscarriage, stillbirth, birth or termination. All of those outcomes should be covered with public money,” she says.
“It shouldn’t be something that institutions can opt out of.”
• This article was amended on 23 August 2023 to include reference to the June 2023 updated inquiry report of the ACT in relation to evidence provided to the inquiry concerning “Calvary public hospital”.
*Name changed to protect identity
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