Her Miscarriage Showed the Limits of California’s Abortion Protections. Where You Live Matters

Anna Nusslock never wanted to be the face of a new kind of reproductive rights battle in California, but when a small Catholic hospital refused to provide an abortion that would end her miscarriage, Nusslock girded herself for a long and difficult conflict.

Nusslock felt her civil rights were being violated, she said, even as she lay in the hospital bed curled in on herself, bleeding and mourning the loss of her twin girls. The doctor had said that her pregnancy needed to be terminated immediately to protect her from infection and other serious complications but hospital policy prohibited it, according to two lawsuits filed by Nusslock and California Attorney General Rob Bonta.

“I am planning to fight this for the rest of my life,” Nusslock said in an interview with CalMatters.

Both complaints allege that Providence, the Catholic health system that owns St. Joseph Hospital in Eureka, illegally denied Nusslock emergency abortion care and discharged her instead. They also allege that multiple pregnant women have been denied abortions at St. Joseph Hospital during medical emergencies.

The disputes playing out in a small courtroom in Eureka highlight the limits of California’s efforts to protect abortion rights since the Supreme Court in 2022 repealed federal protections granted under Roe vs. Wade. They also reveal geographic disparities in patients’ access to reproductive health care after dozens of California hospitals shuttered their maternity wards over the past decade.

Providence has denied the state’s allegations and argued that it provided appropriate care to Nusslock. It contends that its actions are protected by religious liberties that are enshrined in the U.S. Constitution. Humboldt County Superior Court Judge Timothy Canning earlier this month rejected a bid by Providence to dismiss the state’s lawsuit. Providence has filed a request to dismiss Nusslock’s civil suit, which is ongoing.

Catholic companies own about 13% of hospitals in California, but operate 20% of the state’s maternity wards, according to a CalMatters analysis of state data. In the rural northern counties, they represent an even greater share at 35%.

Large corporations such as CommonSpirit (Dignity), Providence, Trinity and Scripps are the most prominent Catholic health care systems in the state.

In Humboldt County where Nusslock lives, Providence now owns the only hospital with an obstetrics department. The next closest maternity ward is 86 miles north along a winding, mostly two-lane stretch of Highway 101.

Last year, Nusslock arrived at Providence St. Joseph Hospital bleeding and in pain but still hopeful her pregnancy could be saved, according to the state’s complaint. Her water had broken at 15 weeks – too early for the twins to survive on their own – and tests indicated Nusslock had an infection and high blood pressure, the complaint says.

Multiple doctors said her condition was dangerous and she needed immediate treatment but Providence refused to intervene because her twins still had fetal heart tones, according to the complaint. Nusslock was discharged with a bucket and towels “in case something happens in the car,” according to the complaint and a declaration filed by Nusslock.

Nusslock’s husband drove her to another hospital about 20 minutes away where she began hemorrhaging and underwent immediate surgery, according to court documents. That hospital, Mad River Community Hospital in Arcata, has since permanently closed its labor and delivery ward, leaving St. Joseph alone in the county.

California’s constitution protects abortion rights, but religiously affiliated hospitals, clinics and individual providers are not required to provide them if they have moral objections. State law, however, requires hospitals to provide emergency services to any person who requests help whose life may be in danger or at risk of “serious injury or illness.”

In an unsigned statement, a Providence spokesperson said the hospital is clear about not performing elective abortions but does allow “medically necessary interventions to protect pregnant patients who are miscarrying or facing serious life-threatening conditions” in an emergency.

“This is consistent with the California Emergency Services Law and the Emergency Medical Treatment and Labor Act. It is also consistent with the Catholic Ethical and Religious Directives, which include discussion of the importance of the physician-patient relationship as well as the circumstances in which certain medical procedures that could result in fetal death may be allowed in a Catholic hospital,” according to the statement provided to CalMatters.

The Catholic Health Association, a trade group representing Catholic health facilities, did not respond to repeated questions about personal belief protections and the expansion of Catholic hospitals.

Religious liberty at heart of hospital’s defense

On a rainy day in February, Harvey Rochman, lead attorney for Providence, argued that religious freedoms protect Providence’s alleged actions.

“The elephant in the room so to speak on this case is there is no court that has ordered a Catholic hospital to perform an abortion under circumstances that the hospital has determined is contrary to the hospital’s faith,” Rochman said during the hearing in Eureka.

The hospital denies that it discriminated against Nusslock or improperly denied care to her. Rochman argued that federal law allows secular hospitals to transfer patients if they do not have the expertise or technical ability to perform a procedure, which is no different from a faith-based hospital saying it cannot perform a procedure that “contravenes” its beliefs.

“The current jurisprudence of the U.S. Supreme Court…is the religious rights have the same significance as the secular,” Rochman said during the hearing.

Catholic hospitals nationwide must adhere to the “Ethical and Religious Directives for Catholic Health Care Services” developed by the U.S. Conference of Catholic Bishops. The directives prohibit abortion in almost all circumstances.

Martine D’Agostino, a deputy attorney general representing the state, argued that the case was about Providence St. Joseph Hospital denying women emergency health care “at great risk to their lives.”

State law prohibits hospitals from transferring patients for non-medical reasons, such as lack of insurance. D’Agostino argued that St. Joseph Hospital did not stabilize Nusslock and illegally discharged her.

“The record details harrowing experiences of several women who were turned away from St. Joseph’s emergency department,” D’Agostino said. “The attorney general brought this case to ensure that St. Joseph Hospital follows the law that emergency health care must be provided to women of this county.”

In declarations filed with the court, multiple doctors allege that other St. Joseph patients have experienced close calls similar to Nusslock’s miscarriage.

One doctor who delivers babies at Providence St. Joseph Hospital said in a declaration that he has had three patients other than Nusslock who needed emergency pregnancy terminations during miscarriages that he was not able to carry out. The declaration states “…the Chaplain told me, that under no circumstances was I to terminate a pregnancy at Providence Hospital.”

Another doctor who later treated Nusslock at Mad River Community Hospital said one to two patients each year would come to the hospital’s now-closed obstetrics department having been turned away from Providence in the midst of a miscarriage.

Another woman has anonymously filed a civil lawsuit in Humboldt Superior Court against Providence alleging similar circumstances to Nusslock. In February, lawyers for Providence filed papers asking a judge to dismiss the case.

Differences in how hospitals treat miscarriage

Although Nusslock’s case is not unique, experts say patient experiences at Catholic hospitals vary widely.

“People always ask me ‘Why are people not dying all over the place?’ And it’s because it’s not exactly that extreme,” said Lori Freedman, a sociologist and bioethicist at UC San Francisco who has extensively researched patient and doctor experiences at Catholic health systems.

Frequently, doctors at Catholic institutions, many of whom are not Catholic, find workarounds to prevent patients from dying, Freedman said. An ethics committee headed by a priest or other religious figure at each hospital decides in the moment whether doctors can intervene. They may wait until the woman develops a fever (a sign of infection), until her bleeding increases or until the fetus dies, Freedman said.

The Ethical and Religious Directives at Catholic hospitals allow pregnancy termination for a “proportionately serious pathological condition of a pregnant woman,” but ethics committees at each hospital can have different interpretations of where to draw the line, Freedman said.

This approach, however, is often shocking to obstetricians in non-religious hospitals, Freedman said.

“When you talk to someone in a really high-quality obstetric service, their jaw drops because they’re like, ‘Well it’s not just die or not die,’” Freedman said. “What kind of level of suffering and risk are you going to require, before the intervention you know is going to happen is allowed to happen?”

The Catholic Health Association states in a policy brief that “Our deeply held religious and moral convictions are the source of both the work we do and the limits on what we will do.”

Those religious and moral convictions include a mandate to continue the “healing ministry of Christ,” to care for the poor, and to advocate for marginalized groups like immigrants, according to the Ethical and Religious Directives.

They also state that the “Catholic health care ministry is rooted in a commitment to promote and defend human dignity; this is the foundation of its concern to respect the sacredness of every human life from the moment of conception until death.”

Maryam Guiahi, an obstetrician in Santa Barbara who has previously worked in Catholic institutions in Chicago, said that’s where Catholic policies begin to conflict with modern secular medical ethics that place different emphasis on patient autonomy and avoiding harm.

In cases like Nusslock’s, in which the amniotic fluid sac breaks before the fetus is viable, terminating the pregnancy is typically the safest option and the standard of care, Guiahi said.

Guiahi said Catholic hospitals sometimes don’t allow doctors to tell patients that an abortion is an option.

“I’ve been in secular institutions and we can give that information. We can let people decide what they want, and some people will choose to continue and hope and see what happens, but other women don’t want to go through that,” Guiahi said.

Not telling patients all of the risks and options compromises their ability to consent and can lead to avoidable complications like infection and hemorrhaging, Guiahi said.

Guiahi said she never saw a patient die after being denied an emergency abortion at the Catholic hospital she worked at, but sometimes patients would come back septic and require care in the intensive care unit.

“To me, medicine is about ‘to do no harm.’ I don’t know many medical situations where we wait till people get sick in order to intervene,” Guiahi said.

Moving to have a baby

Nusslock is making plans to leave Eureka during her next pregnancy. She and her husband still desperately want to start a family, but she can’t drive past Providence St. Joseph Hospital without getting dizzy. She said she has been diagnosed with post-traumatic stress disorder.

“I still have that voice in the back of my head just screaming, ‘you’re bleeding to death,’” Nusslock said.

Most likely Nusslock said she’ll find a place in the Bay Area to live during her pregnancy.

Having few options to give birth reflects a larger loss of maternity services in California. The northern counties, including where Nusslock lives, have lost a third of their birthing hospitals since 2012, according to a CalMatters database on maternity care.

Statewide, 59 hospitals have stopped delivering babies in the same time period, creating broad swaths of maternity deserts particularly in rural and low-income communities.

Nearly 80% of those closures have been secular hospitals, increasing the influence of Catholic health care.

During the February court hearing, Providence lawyer Rochman said that a core mission of the Eureka hospital is to keep labor and delivery services available “when it may not be financially sensible to do so.”

In a statement, a Providence spokesperson said “providing high-quality labor and delivery services” is a “top priority” for the organization in Humboldt County and throughout the nation.

But having an operating maternity ward doesn’t mean all services are available. The Ethical and Religious Directives also prohibit the use of contraceptives to prevent pregnancy, including sterilization for both males and females, and in vitro fertilization.

Josie Urbina, an obstetrician with UC San Francisco Health who specializes in complex family planning, said this creates an unequal patchwork of services in the state.

“It’s unfortunate that in rural parts of California, which happen to be dominated by religious hospitals, that the standard of care is not being followed,” Urbina said. “It’s really just detrimental to patient care.”

For Nusslock, who moved to Eureka 10 years ago and quickly fell in love with the towering redwoods and small-town feel, the lawsuits are about ensuring her experience doesn’t happen to anyone else, she said in an interview with CalMatters.

“These are good people. These are people worth protecting,” Nusslock said. “If they’re going to give me an opportunity to speak for them and fight for them, I’m going to take every opportunity I can.”

CalMatters Data Reporter Erica Yee contributed to this story.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.