Bonnie Wells wanted to have her tubes tied after the birth of her first child in the early 1980s. She was having a cesarean section and planned to get a tubal ligation at the same time to avoid having a separate surgery later.

The Catholic hospital in Northwest Indiana where she delivered told her she wouldn't be able to do it there, because of religious directives, saying she could talk to an outside doctor at her six-week postpartum checkup.

At that follow-up appointment, she found out she was pregnant.

Wells' second daughter was born nine months later, with a disability that left her mostly unable to hear. Wells, unmarried and uninsured, gave her up for adoption.

Wells, of Schneider, has since reunited with her biological child, who's now married with kids of her own. But Wells said that if she could go back and get sterilized before the pregnancy she would.

"I went through a lifetime of, 'Is she OK? Did they take care of her?'" Wells, 57, said of her biological daughter. "She's going to go through a lifetime of being deaf. All they had to do was follow my instructions in the beginning."

With Franciscan Health Crown Point, which is Catholic, and Methodist Hospitals, which is not, discussing a possible merger, both hospitals soon could be Catholic. And the nearest secular hospital to Wells would be Community Hospital in Munster, 45 minutes away.

"My choices are pretty limited, especially if Methodist goes Catholic," she said.

Merger's potential effects on care

Residents and activists have expressed concern over the potential merger's possible limitations on medical care in Northwest Indiana. In March, Franciscan and Methodist, with hospitals in Gary and Merrillville, announced they had signed an exclusive 120-day letter of intent to discuss a partnership.

If the merger is completed, Community Hospital in Munster would be the only non-Catholic hospital in Lake County. (St. Mary Medical Center in Hobart, St. Catherine Hospital in East Chicago and the Franciscan hospitals in Crown Point, Dyer, Hammond and Munster all operate in accordance with ethical and religious directives outlined by the U.S. Conference of Catholic Bishops.)

"(Methodist) would be considered a Catholic hospital if that should happen and, as such, hospital officials would work with Bishop Hying, as they do now, to make sure the hospital follows Catholic health directives," said Debbie Bosak, a spokeswoman for the Diocese of Gary and Bishop Donald Hying.

"This is a responsibility that all bishops take very seriously."

Besides geography, patients can't always choose which hospital system they use because of increasingly narrow health insurance networks. For instance, Community Hospital isn't in network for Managed Health Services, the only insurer expected to sell on the Affordable Care Act (Obamacare) exchange in Lake County for 2018. And hospital systems like Franciscan are increasingly seeking to become the exclusive provider for insurance plans and employers.

Franciscan declined to explain what medical treatments the system permits. "Franciscan is engaged in discussions with Methodist and, until those discussions are completed, we cannot comment," said Michael Shepherd, a spokesman for Franciscan Alliance.

Residents express worry

In the U.S., 1 in 6 hospitals and as many as 1 in 3 in Indiana, now fall under Catholic health care directives, according to a report by the American Civil Liberties Union and Merger Watch, an organization that works to protect a community's access to care when a secular hospital is merging with a religious one.

Some residents of Gary, a largely Protestant city where Methodist has its other hospital campus, have reached out to Merger Watch, said Lois Uttley, director of Merger Watch. She said Catholic health care directives often are misunderstood by the general public.

"When you say no abortions would be allowed at the hospitals, most people say that doesn't affect me because I don't intend to have an abortion," she said.

"But women who become pregnant are at risk for complications and need to be aware there could be restrictions on the health care they get at their local hospital should it become a Catholic hospital system."

She gave as an example an ectopic pregnancy, where the fertilized egg attaches outside the uterus, making the fetus nonviable. Or a premature rupture of membranes, in which the woman's water breaks early in her pregnancy.

"It's a wanted pregnancy. Medically it's not just possible to save the pregnancy at that point," she said. "The woman should be immediately aided to end the pregnancy. If that doesn't happen, there's a high risk of infection. That could affect her future fertility, her ability to try again for a baby."

Activists also have noted that many people in Gary, which has a poverty rate of more than a third, would have a hard time finding transportation to non-Catholic facilities if the merger happens.

"Our communities deserve services they can afford and facilities that respect their beliefs," the Rev. Marie Siroky, a hospital chaplain who lives in Gary, wrote in a recent online article about Catholic health care directives.

At a recent town hall meeting on the merger, Methodist CEO Ray Grady discussed the possibility of putting funds aside for an independent organization that could provide reproductive services in the communities Methodist currently serves.

These types of arrangements have happened in similar mergers. In Troy, New York, for instance, a secular hospital taken over by a Catholic system got an independent license for its maternity ward to bypass the religious directives. A hospital in Seattle funded an adjacent Planned Parenthood clinic before becoming affiliated with a Catholic hospital group.

Not just reproductive care affected

For Sue Ellen Braunlin, a retired anesthesiologist and co-president of the non-denominational advocacy group Indiana Religious Coalition for Reproductive Justice, it matters where Catholic hospitals get their revenue.

"Half the money is private money. The other half is tax money," said Braunlin, who formerly worked for a Catholic hospital. 

She also noted the effects on end-of-life care. For instance, the Catholic directives state: "Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason.

"There (can be a) limit on the amount of pain medicine that can be used in palliative care," Braunlin said of the Catholic directives. "The reason is the doctrine of redemptive suffering. They actually want patients to not get rid of all their suffering because of the redemptive potential of suffering."

Catholic systems like Franciscan also don't provide any care related to gender-reassignment surgery. Franciscan sued the federal government over an Affordable Care Act rule that would have required hospitals not to discriminate based on gender identity.

"Franciscan holds religious beliefs that sexual identity is an objective fact rooted in nature as male or female persons," the lawsuit states. "Like the Catholic Church it serves, Franciscan believes that a person’s sex is ascertained biologically, and not by one’s beliefs, desires, or feelings."

In December, a federal judge ruled in Franciscan's favor and delayed the new policy from going into effect Jan. 1.

Franciscan also fought the Affordable Care Act mandate that required companies to cover birth control for employees. A judge granted Franciscan an injunction from the regulation.

President Donald's Trump administration has indicated it may do away with both rules, anyway.

A treatment denied

Emily Kowalski, of Hammond, was 19 weeks pregnant in summer 2015 when her water broke. She was transported to a local hospital, where she asked if she could be given a medication to induce labor. She said the medical staff told her they could not, because it was a Catholic facility and she was less than 25 weeks along. At the same time, she said they told her, her condition was so severe it would be unsafe to transfer her to another hospital.

"I wanted the baby to be born, and I wanted it to have a heartbeat, and I wanted to hold it while it died," she said. "I didn't want to torture it inside of me until it eventually suffocated itself because there was no fluid in there."

The baby was born three days later, without a heartbeat. Kowalski, now 38, developed an infection and was in the hospital for a week. She has since had two more miscarriages.

"If I could do it over again," she said, "I think I would have risked my life to leave the hospital."

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Giles is the health reporter for The Times, covering the business of health care as well as consumer and public health. He previously wrote about health for the Lawrence (Kansas) Journal-World. He is a graduate of Northern Illinois University.